THIS REGISTRATION FORM CAN BE securely COMPLETED ON A DESKTOP, TABLET OR MOBILE DEVICE
Note: We will be providing Moderna and Pfizer vaccines (Novavax on occassion). Covid-19 Bivalent vaccine booster doses are approved for boosters only and not as primary series vaccine. We do not provide the Flu vaccine currently.
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 that you will be receiving 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. AFHs can register up to 10 residents and/or staff per residential address to receive the Covid-19 vaccine at any one given time. If you have more than 10 residents and/or staff that need to get vaccinated, then you will need to complete a separate registration form for the additional recipients and they will be assigned a different date and time for vaccination.
The purpose of this household-style registration is to help others rejoin their social circle safely and to minimize the detrimental effects of social isolation while streamling the registration process. AFHs registering 2 or more individuals will be prioritized. *For more details, visit our website at www.ChildressNursing.com.
2. Call our office at (206) 310 - 5101 to inquire further about scheduling, canceling or rescheduling an appointment. If we can accommodate your In-Home Covid-19 vaccination request or if we have any questions about your registration, then we will contact you either by phone or email. Also, mark safe and/or check your spam folder for emails from Vaccine@ChildressNursing.com. The best and quickest form of communication with our office is by email.
3. Just because you submitted a 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. Payment for Home Vaccine Services. King County has pre-purchased your Covid-19 vaccination service, and you will not receive a bill from CNS and will not be required to submit your health insurance information for our services.
6. Things you will need during a vaccination home visit
We are honored to be of service to your business!
Childress Nursing Services Team
I am authorized to make the required decisions on behalf of the vaccine recipient(s) listed above. / acknowledge that / have made the Vaccine Information Sheets available for the above recipient(s) and received consent from the vaccine recipient(s) and/or their legal guardian(s) to act on their behalf to give permission to Childress Nursing Services (CNS) and its affiliates for a vaccination to be administered and a record of the vaccine to be entered into a database for use to monitor control of the disease. / and the vaccine recipient(s) represented above shall indemnify and hold Childress Nursing Services (CNS), its affiliates and their representatives and agents harmless from, any and all actual or direct losses, liabilities, judgments, arbitration awards, settlements, damages and costs (collectively, "Losses"), resulting from or arising out of any direct or third party suits, actions, claims, demandsorsimilarproceedings (collectively,"Proceedings")to the extent they are based upon receipt of vaccination services.