• Second Dose Moderna

    This sign-up form is only for persons who have received only one dose of the Moderna COVID-19 vaccine. Please fill this form out, submit and then call our office as we will need to schedule your second dose shot. If this is a first dose request please call our office for the proper form and if this is for a booster of the COVID-19 please visit our website at www.poolesvillefamilypractice.com and fill out the booster form.

  • Sorry you are not eligible

  • If this will be your first dose of the COVID-19 vaccine there is a different form that will need to be filled out. Please call our office at 301-972-7600 and the let the person you speak with know that you have not had a COVID-19 vaccine at all. 

     

    Because you have already had 2 doses of the Moderna COVID vaccine, you will have to fill out our Covid-19 booster form that is available on our website www.poolesvillefamilypractice.com.

  • Positive COVID 19 test

  • Sorry you are not eligible for vaccine at this location

  • If it has been less than 14 days since your COVID positive test OR if you still have symptoms from COVID, we recommend you wait until you met both of these criteria prior to requesting a COVID vaccine.

  • Sorry you are not eligible for vaccine at this time

  • The CDC recommends waiting at least 90 days after receiving passive antibody therapy to start the COVID vaccine series. You may request a COVID vaccine after it has been over 90 days since your treatment.

  • COVID VACCINE CONSENT:

  • Registration Form

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    Pick a Date

  • HIPAA

    A federal law known as HIPAA (the Health Insurance Portability and Accountability Act) requires that medical practices and other medical providers explain to you the rules governing the privacy of your medical records. We comply with HIPAA and all local/state health privacy regulations. If you would like a copy of our official HIPAA policy it is available at the front desk or our website (poolesvillefamilypractice.com ).


    Poolesville Family Practice is only contracted with Medicare (and no other private insurer)

    I understand that Poolesville Family Practice is not contracted with my insurance company (except Medicare). Poolesville Family Practice will submit the bill for your vaccine administration to your insurance, but you are NOT responsible for any out of pocket expenses. If you do not have insurance, we are offering the vaccine without any charges to you. 


    Prescription History Access:

    In order to better care for you, our doctors and staff may need to access your prescription medication history. By signing this document you give us permission to have access to your electronic prescription history.


    Maryland Health Information Exchange:

    We have chosen to participate in the Chesapeake Regional Information System for our Patients, Inc. (CRISP), a statewide health information exchange. As permitted by law, your health information will be shared with this exchange in order to provide faster access, better coordination of care and assist providers and public health officials in making more informed decisions. You may “opt-out” and prevent access of your health information available through CRISP by calling 1-877-952-7477 or completing and submitting an Opt-Out form to CRISP by mail, fax or through their website at www.crisphealth.org.

    Immunet:

    As required by the State of Maryland, we will submit your vaccine records from our office to Immunet. ImmuNet is Maryland’s Immunization Information System (IIS), a confidential and secure database that is HIPAA compliant. It stores an individual’s vaccination records, and is a web-based tool for healthcare providers and schools to keep their patients/students vaccinated on time and avoid under or over vaccination.​


    I agree to all of the above statements and have had all of my questions regarding the above statements answered to my satisfaction.

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