THIS REGISTRATION FORM CAN BE COMPLETED ON A DESKTOP, TABLET OR MOBILE DEVICE
Note: At this time, we will be providing either Pfizer, Moderna, or Janssen (J&J) vaccines.
*Special Note: The registration form's language default is English; however, the form can be translated into 26 different languages by clicking on the upper right hand corner of the registration page and selecting the appropriate language. The form does use an auto translator, so please be advised that some fields may not be properly translated.
ABOUT Childress Nursing Services (CNS)
CNS is a WA state licensed home health agency and mobile clinical laboratory based in Renton, WA that primarily provides fertility and maternal in-home medication injections and support to clients in King, Pierce, and Snohomish counties. Our home health agency is uniquely composed exclusively of licensed nurses. We do focus on serving women from preconception to post-delivery; however, due to the need to have all hands on deck to fight the pandemic, we have decided to join in the efforts to vaccinate Washingtonians against the SARS-CoV-2 virus that causes Covid-19 by providing Covid-19 vaccine home injections.
BEFORE COMPLETING THIS REGISTRATION FORM
Number 1: You (and your household members) should have all of your questions answered about receiving a Covid-19 Vaccine BEFORE SUBMITTING YOUR REGISTRATION as time is of the essence to get as many people vaccinated as possible within the shortest time frame. You can learn more about the Covid-19 Vaccine and get all of your questions answered before registering for the CNS home vaccination service at: https://www.doh.wa.gov/Emergencies/COVID19/VaccineInformation/FrequentlyAskedQuestions
You can also call Washington State's COVID-19 Information Hotline: Dial 1-800-525-0127, then press #. If you can’t reach the hotline via the regular number, then use the alternate number, 888-856-5816 (a Spanish option is available). 6 a.m. to 10 p.m. Monday 6 a.m. to 6 p.m. Tuesday through Sunday, and observed state holidays. Language assistance is available.
Number 2: You (and your household members) should have accessed and read the EUA fact sheets for each Covid-19 Vaccine manufacturer - Pfizer, Moderna and Janseen BEFORE SUBMITTING YOUR REGISTRATION by clicking the links below.
Click here to review the Pfizer-BIONTECH COVID-19 Fact Sheet: https://www.fda.gov/media/144414/download
Click here to review the Moderna COVID-19 Fact Sheet: https://www.fda.gov/media/144638/download
Click here to review the Janssen COVID-19 Fact Sheet: https://www.fda.gov/media/146305/download
1. The primary adult household member can register themselves and up to 9 additional members of the household who want to receive the Covid-19 vaccine. As specific vaccine allocation can vary, the minimum age to register at this time is 18 years old. Household members do not have to be blood relatives and can be people who frequently visit your household, like caregivers or close family/friends. We will not require proof of residency. However, household members must be available for the 2nd dose, if applicable, at the same service address to be scheduled for the 2nd dose appointment set at the scheduled date and time. 2nd dose appointments will be set at the same time as 1st dose appointments, so look at your monthly calendars and schedule accordingly.
The purpose of this household registration is to help others rejoin their social circle safely and to minimize the detrimental effects of social isolation. Households registering 5 or more individuals with at least one household member belonging to the WA state Vaccine Phase 1 through Tier 4 level will be prioritized. *See website for "Priority Booking" order. Registrants with less than 5 members will automatically be placed on the Standby/Wait List. For more details, visit our website at www.ChildressNursing.com.
2. Please do not call our office to inquire about scheduling, canceling or rescheduling an appointment. If we can accommodate your In-Home Covid-19 vaccine injection request or if we have any questions about your registration, then we will contact you either by phone or email. Please allow 1 to 2 weeks to receive a response from our office. Also, mark safe and/or check your spam folder for emails from Vaccine@ChildressNursing.com
3. Just because you submitted a pre-registration form does not automatically mean that you will receive a CNS home vaccine appointment, as state vaccine allocation to providers vary, and our office reviews and priortizes registrations before setting and confirming home Covid-19 vaccine injection visit appointments. Households referred by state/county/city governmental agencies, community-based organizations and/or healthcare practitioners will be considered first.
4. Fill out the form as much as possible. Registrations with missing or incorrect information (especially incorrect/missing contact info with service addresses, phone numbers, and email addresses) will be placed on hold for more information and will be automatically placed at the back of the line, as time is of the essence in vaccinating as many people as possible. Trying to correct or find missing information slows down the process. So, read over the form fields carefully and answer to the best of your knowledge.
5. Health Insurance. The federal government has pre-purchased Covid-19 vaccines. The federal government and insurance companies are required to cover the costs that vaccine administration providers incur to administer the vaccine to their patients/clients. As a result, patients/clients should not receive a bill for the vaccine nor for vaccine administration. If you do receive a bill, then contact your insurance provider first to correct the error. *Note: Please have front and back copies of your insurance card ready to upload. You can take pictures from your device's camera and upload in most major formats. If you do not have health insurance, then please have a copy of your driver's license or state ID available to upload.
6. Things you will need during a vaccination home visit
Some form of photo identification, so our nurses can properly identify the person receiving services. We will not make take photos or request copies of your ID. This can include a state ID, driver's license, passport, work ID, school ID, etc.
If you require an interpreter/translator (all CNS nurses are fluent in English), then you will be responsible for providing an interpreter/translator and any costs associated with having that professional. Ideally, one of the household members should serve as an interpreter/translator. You can contact one of your local community organizations for interpreter/translator support.
CNS will provide the vaccine, nurse vaccinators and supply all medical equipment and supplies needed for the home visit.
As we know that for many people, this may be your 1st home health injection visit. Upon confirmation of your appointment, you will be provided with a "What to Expect" document and supporting materials that will provide further details about your home visit and best tips to prepare
All inquiries or problems with completing this registration form should be sent to our office email address: Vaccine@ChildressNursing.com. Please allow 1 to 2 weeks for a response.
We are honored to be of service to you and your family!
Childress Nursing Services Team