Vaccine Pre-Registration

COVID-19 Vaccine Pre-Registration

*Patient Will Be Contacted To Make Appointment When Eligible
Patient Name *

First Name Last Name
Birth Date *

Month Day Year
Date
Social Security Number
All information on this form is Encrypted to comply with HIPAA requirements.
Gender *

Female Male
Phone Number *
Please enter a valid phone number.
Email Address *
Please provide a valid email address for copies to be emailed to you.
Patient Address *

Street Address

Street Address Line 2

City Missouri Residents Only

Zip Code
Emergency Contact Information *

First Name Last Name
Phone Number *
Please enter the phone number for your Emergency Contact.

Insurance Information Sheet
There is no co-pay for the COVID-19 vaccine, the Federal Government has allocated funds to cover those costs. However, Old Town Pharmacy will need to submit a claim through your insurance cards so that we will get reimbursed for administering the vaccine to you, your insurance will then be reimbursed by the Federal Government.

If you do not have insurance, the Federal Governement will still cover the cost, but it changes the way we are required to submit for the reimbursment.

If you are insured, uploading your insurance cards on this page will expedite your vaccination process and will allow us to vaccinate more people in a single day.
Do you have insurance coverage? *
Front of Insurance Card *
Back of Insurance Card *

Vaccine Phase Eligibility

COVID-19 Vaccine Eligibility Form
Missouri's Current Vaccine Distribution Phase Eligibility, Leave Blank if None Apply:

Direct-Contact Healthcare Worker (Physician, Nurse, Aide, Therapist, Clinical Area Janitorial Staff, Medical Receptionist, Etc.) Public-Facing Public Health Worker (engaging public to implement state response plan) First Responder (non-hospital EMS, Law Enforcement, Fire, and Corrections Officers) High Risk Individual (65+, Other High Risk Factors) Child Care Worker Teachers / Staff (School personnel, regardless of duties)
I HEREBY DECLARE THAT THE ABOVE STATEMENTS ARE TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE AND BELIEF. *

Clear
Would you like to help us improve this form?

Yes. No thanks.
Should be Empty:

COVID-19 Vaccine Pre-Registration