Pediatric COVID-19 Vaccine Appointment Form

Pediatric COVID-19 Vaccine Appointment Form

This form is for scheduling vaccination appointments for those ages 6 months to 11 years. For appointments for those 12 and older, please return to our website healthygallatin.org
Please select a time for your vaccination appointment*
Please note that all appointments are being held at the Gallatin City-County Health Department located at 215 W Mendenhall St.
Personal Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
These appointments are for individuals 6 months to 11 years of age. For appointments for those 12 and older , please return to our website healthygallatin.org
What is your gender?*
What is your race?*
What is your ethnicity?*
Email*
A confirmation of your appointment will be sent to the email address entered above.
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState

Zip Code

Health Insurance
The vaccine is being provided at no cost. Your insurace may be charged for the costs of adminstering your vaccination.
Insurance Type*
Insurance Company Name
Member ID Number
Group Number
Medical Assistance Number, Recipient Number, or any other number on card
Policy Holder Name

First NameLast Name
Policy Holder Date of Birth

MonthDayYear
Date
Policy Holder Relation to Client
Take a photo of the FRONT of your insurance card (optional)
Take a photo of the BACK of your insurance card (optional)

Consent for Services
Please select your desired vaccine.

Moderna COVID-19 Vaccine (6 months-5 years)Pfizer-BioNTech COVID-19 Vaccine (5-11)
Please select your desired vaccine.

Pfizer Bivalent Booster (5-11)Moderna Bivalent Booster (6-11)Moderna Bivalent Booster (6 months-5 years)
Please select the link to the corresponding desired vaccine to review the vaccine information prior to consenting & signing below.

Pfizer (5-11) vaccine info - https://www.fda.gov/media/153717/download

Moderna (6 months - 5 Years) vaccine info - https://eua.modernatx.com/covid19vaccine-eua/6m-5y-facts-recipient.pdf

Moderna (6-11) vaccine info - https://eua.modernatx.com/covid19vaccine-eua/bivalent-dose-recipient.pdf
Consent for Vaccination - You Must Sign This to be Vaccinated*

By signing this form, I am requesting vaccination services for myself and/or the persons identified, of whom I am authorized to sign. A copy of the appropriate Centers for Disease Control and Prevention Vaccine Information Statement(s) has been provided. I have read the information about the disease(s) and the vaccine(s) listed. I believe that I understand the benefits and risks of the vaccine(s) cited and ask that the vaccine(s) listed be given to me or to the person named (for whom I am authorized to make this request).
I authorize this health care provider and a public health agency to collect and enter immunization records into the Department of Public Health and Human Services’ Immunization Information System (IIS). The IIS is a confidential, computer system that contains immunization records. I understand that information in the registry may be released to a public health agency as well as my or my child's health care providers to assist in medical care and treatment. In addition, information may be released to child care facilities or schools in order to comply with immunization requirements. I understand that I can revoke this authorization and have my or my child's record removed at any time by contacting the State of Montana Immunization Program.
Please sign your name here*

Clear
If you are unable to sign your name, please type your name below

First NameLast Name
Today's Date

MonthDayYear
Date
Relationship to Patient*
Name*

First NameLast Name
Should be Empty:

Pediatric COVID-19 Vaccine Appointment Form

Personal Information

Health Insurance

Health Questions

Consent for Services