2022 COVID Vaccine Pre-Registration for Community Members

COVID Vaccine Pre-Registration for Community Members

Parents/Caregivers or patients please fill out the form below in order to schedule the first dose of your COVID-Vaccine. The Pfizer-BioNtech COVID-19 and Moderna vaccine are currently available for children and adults 6 months and up.
Patient's name*

First NameLast Name
Parent/ Guardian's Name (If under 18)

First NameLast Name
Patient's Date of Birth*

MonthDayYear
Date
Age*
Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Patient Email (If pt > 18yo)*
example@example.com
Patient Phone Number (If pt > 18yo)*
Please enter a valid phone number.

Questionnaire for Immunization
Which COVID-19 dose do you need? (choose one)*

First doseSecond dose onlyA booster (if eligible)An additional dose (for patients with weakened immune system due to chronic health condition or medication)
Please note that the bivalent COVID booster is now the only one available for those ages 12 and up. Ages 12 and up are eligible to receive the bivalent booster 2 months after their second dose or last booster. Children ages 5-11 may recieve one orignal (monovalent) booster 5 months after their second dose of Pfizer or Moderna. Learn more about COVID boosters on the CDC website.
You are eligible for an additional (third) dose if you have completed the initial two dose series of the Pfizer-BioNtech or Moderna vaccines over 28 days ago and meet the CDC additional dose eligibility requirements. By selecting this option you are confirming you meet the eligibility requirements.

Insurance Information
THERE IS NO COST TO YOU. I (the patient) hereby authorize Kim A. Kelly MD, PC to apply for benefits on my behalf for all services rendered with my insurance. I (the patient) certify the information provided regarding my insurance coverage is correct. I (the patient) further authorize the release of any and all information necessary for my insurance company to determine benefits for services rendered. I (the patient) request payment of authorized benefits be made payable to Kim A. Kelly MD, PC on my behalf.

If I (the patient) do not have insurance, I (the patient) have truthfully indicated below and will not be responsible for the cost. I (the patient) acknowledge that if I (the patient) do not have insurance, my information will be submitted to the U.S. Department of Health and Human Services’ Health Resources and Services Administration (HRSA) so that Kim A. Kelly MD, PC will be funded for the cost of my immunization administration.

If I (the patient) have Medicare, Medicaid or other government insurance, I (the patient) authorize the release of my medical or other information necessary to process this claim. I (the patient) also request payment of government benefits either to myself or to the party who accepts assignment.

I (the patient or parent/guardian if patient is under 18 years of age) have read the above and have provided Kim A. Kelly MD, PC with true and correct information and will notify Kim A. Kelly MD, PC of any changes in health insurance coverage.
Does the patient have health insurance?*

Private insuranceMedicaidMedicareNo insurance
Insurance Company*
Policy Holder*
Policy Holder Date of Birth*

MonthDayYear
Date
Subscriber ID/Policy Number*
Medicare ID or Social Security Number*
Social Security Number*
Please upload pictures of the front & back of your insurance card.*

Cancelof

Signatures
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA), a copy of which was provided to me at the time of registration. I have had a chance to ask questions that were answered to my satisfaction.

I agree to WAIT near the clinic location for 15 minutes after receiving the vaccine. If I or my child have previously had a severe allergic reaction to a vaccine or injectable medication, I agree to WAIT near the clinic location for 30 minutes after receiving the vaccine.

I understand that the COVID-19 vaccine is a two-part vaccine series. By signing this consent, I am agreeing that I or my child will receive the first and second part of the vaccine series.

I understand that the vaccination is being given by Kim A. Kelly MD, PC. The owner and/or operator of this site, their affiliates, officers, directors, employees and agents expressly disclaim any responsibility for the vaccination. My consent is given in light of this knowledge, and in consideration of Kim A. Kelly MD, PC giving the COVID-19 vaccine. I, for myself and my heirs and family members, administrators, trustees, executors, assigns and successors in interest do hereby agree to release and hold harmless Kim A. Kelly MD, PC, its subsidiaries, divisions, affiliates, successors, assigns, officers, trustees, employees, volunteers and agents from and against any and all demands, damages, losses, costs, expenses, obligations, liabilities, claims, actions and cause of action (whether any of which is groundless or otherwise) of any nature whatsoever (including, without limitation, reasonable attorney’s fees and court costs) by reason of or resulting, in any way, from any and all acts, accidents, events, occurrences, omissions and the like related to, or arising out of, directly or indirectly, my receipt of this COVID-19 vaccine.

I further understand that my provider is required to submit COVID-19 vaccine administration data to ImmuNet, Maryland's Immunization Information System. I was also offered a copy of the Kim A. Kelly MD, PC Notice of Privacy Practices at the time of registration.

Moderna EUA

Pfizer EUA 12 and up

Pfizer EUA 5-11

Notice of Privacy Practices
I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent and Release.
I authorize Kim A. Kelly MD, PC to bill my insurance on my behalf for the immunization administration.
If uninsured, you must check the box below to attest that the following information 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
Signature*

Clear
Name of Signer *
Relationship to Patient (If patient is under 18 years of age)
Should be Empty:

	Yes	No
Has the patient ever had a severe allergic reaction to another vaccine (other than the COVID-19 vaccine) or injectable medication?
Has patient had a severe allergic reaction to a component of the COVID-19 vaccine, including polysorbate or polyethelene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures?
Has the patient ever had a severe allergic reaction to a previous dose of the COVID -19 vaccine?
Has the patient tested positive for COVID-19 in the last 90 days?
Does patient have a weakened immune system caused by something such as HIV infection or cancer or do they take immunosuppressive drugs or therapies?

COVID Vaccine Pre-Registration for Community Members

Questionnaire for Immunization

Insurance Information

Signatures