COVID-19 Consent & Registration Form

Do you have allergies?*

YesNo

Please list all of your allergies

If no allergies type "None"

Please list all of your allergic reactions to each allergy

Patient Name*

First NameLast Name

Date of Birth*

Must be 12+ years of age for completing this form.

Address*

Street Address Including Apartment Number

City

State/ProvincePostal/Zip Code

County of Residence i.e., Platte, Clay, Jackson, etc.

Home Phone Number*

Please enter a valid phone number. If no home phone, please put your cell phone number.

Cell Phone Number*

Please enter a valid phone number. If no cell phone, please put your home phone number.

Race*

Ethnicity*

Hispanic/LatinoNot Hispanic/LatinoOther

Sex*

MaleFemale

Insurance Type*

Medicaid DCN #

If uninsured, you must check the bow below to attest that the following is true and accurate:

I do not have any insurance, including but not limited to Medicare, Medicaid, or any other private or government-funded health benefit plan.

In order to have your vaccine administration fee paid for by the United States Health & Services Administrator's COVID-19 Program for Uninsured Patients, please provide either (a) a valid social security number, (b) state identification number and state of issuance, OR (c) a driver's license number and the state of issuance.

Please enter your Social Security Number Or State Identification Number & State, Or Driver's License Number & State

Name of Primary Health Insurance

Name of Policy Holder

Policy Holder Phone Number

Please enter a valid phone number.

Policy Holder Date of Birth

Date

Policy Holder Address:

Address

Policy or Member Numbers

Group Number

Customer Service Number on the Back of the Insurance Card

Please enter a valid phone number.

Personal Financial Responsibility: By signing this form, and in return for the services rendered by the Platte County Health Department (PCHD), I am personally responsible for all fees not paid by any third party on my behalf.

Assignment of Insurance Benefits: I hereby assign all my interest and rights to all insurance benefits otherwise payable to me from any policy to PCHD. I agree that PCHD may disclose any portion of my medical, financial, or personal information to any person or organization requiring such information as a condition of paying, receiving payment for, or justifying payment for my health care or the health care of one for whom I am responsible. I further authorize payment of all insurance benefits, otherwise payable to me, for all treatment provided directly to PCHD. I understand that I am responsible for any amount not covered by insurance.

My signature indicates that I have reviewed a copy of the “Notices of Privacy Practices” and have read the Emergency Use Authorization (EUA) Fact Sheet for Recipients/Caregivers and/or Vaccine Information Statement (VIS) for the vaccine(s) that I am requesting be given to the person named on the form.

Signature of Patient, Parent, or Legal Guardian (Use mouse, stylus, or finger to sign)*

Clear

Printed Name of Patient, Parent or Legal Guardian*

Date Signed*

Date

Relationship to Patient *

(Self, Parent, Legal Guardian)

COVID-19 & Flu Consent & Registration Form

Health History Screening Tool

Health History