Pediatric COVID Vaccine Appointment

Pediatric COVID Vaccine Appointment

For Children 6 months to 11 years old
Please note that all appointments are being held at the Gallatin City-County Health Department located at 215 W Mendenhall St.

For ages 12 and older, please return to our website: https://healthygallatin.org
Appointment
Personal Information of person being vaccinated
Name*

First NameLast Name
Date of Birth*

MonthDayYear
These appointment requests are for individuals 6 months to 11 years of age. For appointments for those 12 years and older, please return to our website healthygallatin.org
Gender?*
Race?
Ethnicity?
Guardian's Email*
Guardian's Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState

Zip Code

Health Insurance
The cost of the vaccine should be covered by insurance companies or the VFC (Vaccines for Children) program.
Insurance Type*
Insurance Company Name
Member ID Number
Group Number
(Type NONE if there is not a group # listed)
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)

Personal Information of person being vaccinated