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 home vaccinations.

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 and/or Moderna that you will be receiving BEFORE SUBMITTING YOUR REGISTRATION by clicking the links below: 

Click the applicable links to review the Fact Sheet for the appropriate age group COVID-19 vaccine manufacturer for your household:

PFIZER

Pfizer: 6 months through 4 years of age: https://www.fda.gov/media/159313/download  

Pfizer: 5 years through 11 years of age: https://www.fda.gov/media/153717/download  

Pfizer: 12 years of age and older: https://www.fda.gov/media/153716/download  

MODERNA

Moderna: 6 months through 5 years of age: https://www.fda.gov/media/159309/download  

Moderna: 6 years through 11 years of age: https://www.fda.gov/media/159310/download  

Moderna: 12 years and older: https://www.fda.gov/media/144638/download  

INSTRUCTIONS

1. The business or household representative can register up to 5 members per household address to receive the Covid-19 vaccine. As specific vaccine allocation can vary, the minimum age to register at this time is 18 years old for Moderna and 12 years old for Pfizer. 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 2 or more individuals will be prioritized. *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 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

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. Required fields are mark via a red asterick and must be completed in order to submit the form. If you submit this form and do not receive a confirmation email in your inbox or spam folder, then that means that your form was not received by our office. You will need to resubmit the form, until you receive confirmation. 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 home vaccination service. As a result, 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

• If you require an interpreter/translator (all CNS nurses are fluent in English), then you will need to indicate on the form, and we will see what options are available for you. Ideally, one of the household members should serve as an interpreter/translator. 
• Please have a caregiver or adult household member available during the appointment for all clients receiving vaccination services who have physical, behavioral or cognitive limitations.
• CNS will provide the vaccine, nurse vaccinators and supply all medical equipment and supplies needed for the home visit.
• 
  All inquiries or problems with completing this registration form OR cancellation OR rescheduling appointments should be sent to our office email address: Vaccine@ChildressNursing.com (quickest response) or call us at 206-310-5101. 

We are honored to be of service to you and your family!

Childress Nursing Services Team

I am authorized to make the required decisions on behalf of the vaccine recipient(s) listed above. / acknowledge that I have made the Vaccine Information Sheets available for the above recipient(s) or myself and have received consent from the vaccine recipient(s) and/or their legal guardian(s) or give consent to act on my or 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. I and/or 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.