• with Carpe Diem Health PLLC

    with Carpe Diem Health PLLC

    A Texas COVID-19 Vaccine Provider
  • COVID-19 Vaccine Registration and Consent Form

    Vaccination Clinic at Pediatric Associates of Dallas
  • 01/03/23 Update.  

    PFIZER BIVALENT (6 mo- 4 years) is now available.   This bivalent dose will replace shot #3 in the COVID vaccination series.  Please note, this is not authorized as a booster dose for children who have already received 3 doses in the Pfizer (6 mo - 4 year) series.  Those children should not sign up for a bivalent vaccine as they are considered fully immunized by the current guidelines.  

    MODERNA BIVALENT BOOSTER (6 months - 5 years) is now available. 

     Who is eligible for this?   Children ages 6mo - 5 years that received both doses of the Moderna vaccination series and their second dose was at least 8 weeks ago.  

    The Moderna 6 mo- 5year serires is now: Dose 1 (original).  4 weeks later Dose 2 (original).  8 weeks later : Moderna bivalent booster 

    If your child has received doses 1 and 2 of Pfizer 6 mo - 4 years, your 3rd dose will now be the Pfizer 6 mo-4 year bivalent vaccine.   This will be given at least 8 weeks after the second original dose in the series was received.   

    Pfizer 6mo- 4year series is now:  Dose 1 (original).  3 weeks later Dose 2 (original).  8 weeks later Dose 3 (bivalent dose).   

     

    Current CDC Covid-19 Vaccination Schedule

     

    Children who are just beginning their 6 mo - 5 year old vaccines will choose one of those two pathways above.  

    All doses will be available immediately at the clinics below.  

    Questions: vaccinations@DocDashDFW.com

     

  •  Clinic Location: 

    Pediatric Associates of Dallas

    (Entrance is the 2nd floor of the parking ramp)

    7859 Walnut Hl Ln #200, Dallas, TX 75230

     

     

    Steps to register:

    1. Complete this form for each person receiving a vaccination, and for each dose of vaccination you need.   So a child receiving the Lil' Pfizer vaccination will need to complete this form three times, once for each dose in the series.  The form serves as a consent to give each dose and this is a CDC requirement.  It allows you to answer if there were any allergic reactions or concerns after each dose as well.  We use the data from each clinic date chosen below to know how many of each vaccine to prepare the morning of the clinic.  We appreciate the time it takes to do this, and apologize for the redundancy. 

    2. After submitting this form, you will be taken to a Sign Up Genius page to select a time slot on the day you registered for.   This is a tool to help space clinic arrivals and minimize waiting times.  Please select an open time slot.   If you miss your time slot, you are fine, please come when you can.   

    If the Sign Up Genius is full on the date you registered for, simply skip this step.  As a scheduling tool it has maximized its value.   Arrive any time the clinic is open as we always vaccinate in the order of arrival.   This process has worked well and wait times are very reasonable.  So bottom line: do not change your registration date if the Sign Up Genius is full.  We will have your vaccine ready to go.   

    As a reminder, Carpe Diem Health PLLC does not recieve your insurance information from Pediatric Associates of Dallas.  Please take a moment and supply the information from your card below when your register. 

    There is no copay and nothing is billed to you / or due out of pocket for COVID19 vaccinations.  Carpe Diem Health will bill your insurance for the shot administration fee.

    If you do not have insurance at this time, please sign up for COVID vaccinations for you and your family at no cost.  Simply leave the insurance boxes blank when you register your form(s).

     3. You will receive an email after registering with the form information and your selected clinic date.   You will receive a separate email from the Sign Up Genius software when/ if you choose a time slot.

    4. You will receive a final email after your vaccination is complete, which will have a PDF attachment of your vaccine record for your files.

     Vaccinations are registered with ImmTrac2, the Texas Immunization Registry. 

     

    Let us know if you have any feedback!  We are always open to suggestions and ways to improve your experience.

    Email:

    Vaccinations@DocDashDFW.com

    Medical questions or concerns to: 

    Dr.Chris@DocDashDFW.com 

    or leave a voicemail or a text message to (972) 846-9550.

      

    Vaccinations administered by Carpe Diem Health PLLC, a Texas COVID-19 vaccination provider. 

  • PATIENT INFORMATION

  •  / /
    Pick a Date
  •  
  •  / /
    Pick a Date
  • INSURANCE STATUS.  Please note we do not receive your insurance information from Pediatric Associates of Dallas.  Thank you for completing this section for Carpe Diem Health PLLC.   We will bill your insurance for the shot administration fee, with no copay or out of pocket charged to you.   This is important as it will allow us to continue to provide this on-site service with PAD.

  •  
  • CONSENT FOR VACCINATION - To be completed by the vaccine recipient, or the Guardian if under 18 years of age

  •  
  • Clear
  •  / /
    Pick a Date
  • Below are Patient Fact Sheets from each COVID-19 vaccine manufacturer.  Please review the fact sheet associated with your scheduled vaccination. 

    If you have any questions, please ask at the time of your vaccine, or by voice message or text message to Carpe Diem Health PLLC (972) 846-9550 at any time.  Email at Vaccinations@DocDashDFW.com

     

     

    Pfizer-BioNTech COVID19 Vaccine Fact Sheet from 6 months through 4 years of age

    Moderna COVID19 Fact Sheet for 6 months through 5 years of age

    Pfizer-BioNTech COVID19 Vaccine Fact Sheet for 5 through 11 years of age

     Moderna COVID19 Vaccine Fact Sheet age 6 through 11 years

    Pfizer-BioNTech COVID-19 Vaccine Fact Sheet

    Moderna COVID-19 Vaccine Fact Sheet

    Novavax COVID-19 Vaccine Fact Sheet

    Moderna BIVALENT BOOSTER Fact Sheet

    Pfizer BioNTech BIVALENT BOOSTER Fact Sheet

     

     

     

    When your vaccination is complete, you will receive the CDC COVID-19 Vaccination Record Card.   If this is your 2nd or 3rd COVID-19 vaccination, please bring your CDC vaccination card and we will update it.

     

     

     Submit your form using the link below.  You will be taken to a SIGN ME UP GENIUS link from PAD, to select your desired arrival time slot.   Participating with this SIGN ME UP GENIUS tool helps to minimize wait times for all on by spacing arrivals.

     

     

    • COVID-19 VACCINE ADMINISTRATION  
    •  - -
      Pick a Date
    • Should be Empty: