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  • COVID Vaccine Appointment

    The following questions will help us determine if there is any reason you should not get the COVID-19 vaccine today. If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions may be asked. If a question is not clear, please ask your healthcare provider to explain it. This form is for both kids and adults. For children, the form should be filled out with the child's information (phone number and email can be a parent or legal guardian's). Please answer questions that apply to your age group and as best as you can. Thank you.
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  • If you do not see a "Next" button, you are filling out the incorrect form for the type of appointment you are requesting
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  • Consent

    • I certify that I am: (a) the patient or the guardian of the patient and I am at least 18 years of age; (b) the parent or legal guardian of the patient and confirm that the patient is at least 6 months or above; or (c) authorized to consent for vaccination for the patient named above. Further, I hereby give my consent to Minneapolis Health Clinic PLLC or its associates to administer the COVID-19 vaccine.
    • I understand that this product has not been approved or licensed by FDA, but has been authorized for emergency use by FDA, under an EUA to prevent Coronavirus Disease 2019 (COVID-19) for use in individuals 12 years and years and older; and the emergency use of this product is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of the medical product under Section 564(b)(1) of the FD&C Act unless the declaration is terminated or authorization revoked sooner.
    • I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccine(s). I understand the risks and benefits associated with the above vaccine and have received, read and/or had explained to me the Emergency Use Authorization Fact Sheet on the COVID-19 vaccine I have elected to receive. I also acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction.
    • I acknowledge that I have been advised to remain near the vaccination location for approximately 15 minutes after administration for observation; and for 30 minutes if I have a history of anaphylaxis from any cause. If I experience a severe reaction, I will call 9-1-1 or go to the nearest hospital.
    • On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless Minneapolis Health Clinic, and their staff, associates, successors, divisions, affiliates, subsidiaries, officers, directors, contractors and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the vaccine listed above.
    • I acknowledge that: (a) I understand the purposes/benefits of MN-Health Information Exchange, Minnesota immunization registry and (b) will include my personal immunization information in MN-HIE and my personal immunization information will be shared with the Centers for Disease Control (CDC) or other federal agencies.
    • I acknowledge receipt of the Notice of Privacy Rights.

  • By signing, I have completed this form to the best of my knowledge and consent to the agreement as written and receipt of vaccine.

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  • COVID Vaccine Appointment Policies
    (Please read carefully... it's really important!)

    Things you will need to bring:
    Picture ID
    Insurance card (for verification)
    Vaccine Card (if you do not have one, that's okay!)     

    There is a 10 minute late policy for all patients.
    Please call us immediately if you are going to be late.
    Minneapolis Health Clinic reserves the right to deny testing if you arrive more than 10 minutes late for your appointment - the final decision is non-negotiable. 

     

    If you need to cancel, call our office so we can offer this spot to someone else. You may still get an appointment reminder from our system on the day of your cancelled appointment.

     

    Please check your junk mail if you do not see a confirmation email. If you do not receive anything, this may be due to your security settings.

     

     

    Minneapolis Health Clinic, PLLC
    4825 Olson Memorial Hwy
    Golden Valley, MN 55422
    Phone: (763)496-5708

     


    We look forward to seeing you!

     

     

    Please be kind to our staff! Minneapolis Health Clinic PLLC has a zero-tolerance harassment policy. If a patient is found to be violating this policy, clinic staff reserve the right to refuse service.

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