Square Care COVID-19 Vaccine Registration

Square Care Medical & Pharmacy COVID-19 Vaccine Registration

Please pick a time and fill out the information below.
Appointment *
Please fill out the below form.
Salutation
First Name *
Middle Name
Last Name *
Date of Birth *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Email (must be unique to each individual) *
example@example.com
This is my First, Second, or Third dose of the COVID-19 Vaccine:

First dose Second dose Booster
Which Vaccine are you requesting *

Pfizer (All doses - 12+ yo) Pfizer Pediatric (All doses 5-11 yo) Moderna (All doses - 18+ yo) Moderna (6 months +)
By completing these fields you are attesting that you are 5+ years of age. *

I am 5-11 years of age I am 12 years of age I am 13-17 years of age I am 18+ I am 6 months +
What County do you live in ? *
Parent or Legal Guardian Name ( Only applicable if a patient is 18 years of age or younger)

First Name Last Name
Parent or Legal Guardian date of Birth ( Only applicable if patient is 18 years of age or younger)

Month Day Year
Date
Please review and check ALL the boxes below *

Please bring your ID and Insurance card with you to your appointment Please arrive as close to your appointment time as possible to prevent traffic congestion or delays Please allow 30 minutes upon arrival. You will be required to remain on site for at least 15 minutes for observation. Additional instructions will be provided upon arrival. If the patient is 17 years or younger, a parent or legal guardian must accompany the patient during the vaccine process. If readily accessible, please bring the child's ID or birth certificate.
Please review and check the boxes below *

We recommend you to remain on site for 15 minutes for observation. Additional instructions will be provided upon arrival.
Please review the following:

Moderna Fact Sheet - https://www.fda.gov/media/144638/download

Pfizer Fact Sheet - https://www.fda.gov/media/153716/download

J&J EUA Fact Sheet - link

V-Safe Registration - Get vaccinated. Get your smartphone. Get started with v-safe. (cdc.gov)
Please make sure you review the Pfizer, Moderna, or "J&J Fact Sheet" and "V-Safe Registration" above. *

I attest that I have reviewed Pfizer, Moderna or "J&J Fact Sheet" and "V-Safe Registration" above.
Please download and review the form below from the CDC.

https://squarecarerx.com/wp-content/uploads/2021/11/pre-vaccination-screening-form.pdf
Please agree to the following *

I have downloaded and reviewed the form from the CDC link above.
Please agree to the following *

Please remember to bring your ID and insurance card to the appointment.
Should be Empty:

Square Care Medical & Pharmacy COVID-19 Vaccine Registration

Please fill out the below form.