Hilltop COVID-19 Vaccine

COVID-19 Vaccine Registration Form

Hilltop Regional Health Center
HRHC

Clinic Location:
Hilltop Regional Health Center
1202 Martin Luther King Jr. Way
Tacoma, WA 98405

Appointments are recommended, but a limited number of Walk In spaces are available.

You can get these COVID-19 vaccines at this location:
- Pfizer: Authorized for people 12 years or older.
  - Requires 2 doses at least 21 days apart.
  - A parent or guardian signature on the pediatric consent form is required if under 18 years old.
- Moderna: Authorized for people 18 years or older.
  - Requires 2 doses at least 28 days apart.
Arrive for your appointment no more than 15 minutes early to fill out additional paperwork before your vaccine.

If you need to cancel your appointment please call 253-722-1855 or email development@commhealth.org.

If you have received your vaccine at a different location, please contact us to cancel your appointment.

Please note: If no times are listed or the form will not let you register, the appointments for the day are full.
Please select the option that applies to you *

Yes, I am 12 years or older and currently eligible to get COVID-19 vaccine. No, I am not 12 years or older.
Patient Name *

First Name Last Name
Patient Birth Date *

Month Day Year
Date
Are you a current patient of Community Health Care? *

Yes No
Will this be your first dose of COVID-19 Vaccine? *

First dose Second Dose
Which type of vaccine was your first dose?

Moderna Pfizer Johnson & Johnson/Janssen
The Johnson & Johnson/Janssen vaccine is a single dose vaccine. A second shot appointment is not needed.
Appointment Time *
Email *
example@example.com
Phone Number *
Please enter a valid phone number.
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
I live in public housing *

Yes No
I am currently homeless *

Yes No
What ethnicity do you consider yourself? *

Hispanic or Latino Not Hispanic or Latino
What race do you consider yourself? *

American Indian/Alaskan Native Asian Black/African American Hawaiian Native Other Pacific Islander White/Caucasian I prefer not to answer Other
I currently have health insurance. *

Yes No
There is no charge to recieve the vaccine. This question is for reporting purposes.
I hereby declare that all the given information are accurate. *

Yes No
I am filling this form out on behalf of a patient who has given me express permission to do so.
Name

First Name Last Name
You can't register for this vaccine event. To find out more about the COVID19 vaccine visit tpchd.org/vaxtothefuture.
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COVID-19 Vaccine Registration Form