COVID Vaccine Consent Form

COVID-19 Vaccine Appointment Scheduling

* Please fill out the required details below
If you have remaining questions, please call us at (423)-639-5155.

Anyone age 18 or older are now eligible
Section I. Personal Information
Patient's Full Name: *

First Name Last Name
Age *
NO ONE UNDER THE AGE OF 18 CAN RECEIVE THE MODERNA COVID-19 VACCINE
Date of Birth: *

Month Day Year
Phone Number: *
Email:
Gender:

Male Female
Ethnicity:

Hispanic or Latino Non Hispanic/Latino Unknown Prefer not to answer
Race:

African American American Indian Asian Caucasian/White Native Hawaiian/Other Pacific Islander Prefer not to answer
What dose of COVID-19 vaccine will this be? *

First Dose Second Dose
When did you receive your first dose? *

Month Day Year
Date
Section II. Scheduling Your Appointment
**Vaccine supply is limited. Please keep your appointment or call if you need to cancel or change it. Additionally, due to vaccine requirements; we may call you to see if you can come earlier, later or to a nearby location. If you miss an appointment, no doses will be held to guarantee your dose.**
THERE ARE A LIMITED NUMBER OF APPOINTMENTS AVAILABLE DAILY. IF THERE ARE NO DATES OR TIMES AVAILABLE, PLEASE KEEP CHECKING BACK FOR NEW APPOINTMENTS TO OPEN UP. THANK YOU FOR YOUR PATIENCE!!
Please pick a day and time for your vaccination *
By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.
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COVID-19 Vaccine Appointment Scheduling

THERE ARE A LIMITED NUMBER OF APPOINTMENTS AVAILABLE DAILY. IF THERE ARE NO DATES OR TIMES AVAILABLE, PLEASE KEEP CHECKING BACK FOR NEW APPOINTMENTS TO OPEN UP. THANK YOU FOR YOUR PATIENCE!!