RequiredVaccineRegInfo

REQUIRED INFORMATION FOR BOOKING COVID VACCINE APPOINTMENT

Below are information we need from you in order for the volunteer to help you register for the COVID-19 vaccine appointment. Fields marked with * are required fields.

Note: These are the questions we collected based on people who have already registered vaccine appointment online. It could vary from providers. We are getting the information so that volunteer has enough information to help you secure an appointment.
All these info will be deleted and shredded once you or the volunteer is able to secure a spot for your vaccination appointment.

Your Personal Information

* Indicates required field

First Name *

Middle Name *

Last Name *

Email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Date of Birth (mm/dd/yyyy) *

Race / Ethnicity *

Your Current Medical Status

Depending on provider, questions below may be asked online or both online and in-person at the time of appointment.
For volunteers to make your appointment, you must answer NO to all of them.
If you answer YES to any of these, please let your volunteer know and you might want make your own appointment, as we are not sure how the system will handle follow-up questions and if there are additional requirements associated with these conditions.

Are you feeling sick today?
Have you ever received a dose of COVID-19 vaccine?
Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something? For example, a reaction for which you were treated with epinephrine or EpiPen®, or for which you had to go to the hospital?
Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?
Have you received another vaccine in the last 14 days?
Have you had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?
Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
Do you have a bleeding disorder or are you taking a blood thinner?
Are you pregnant or breastfeeding?
Was the severe allergic reaction after receiving a COVID-19 vaccine?
Was the severe allergic reaction after receiving another vaccine or another injectable medication?

Please confirm "NO" to all questions above *

Yes, I confirm all "NO"s to all questions above

Your Insurance Information

Below are the health information that are usually required to register for the vaccine.
We leaving this option since we were told that vaccine is available to everyone. Thus, insurance information may not be required (but we are not certain if this applies to all sites).
If you are comfortable providing info, please fill out the fields below.
If you are NOT comfortable providing the info, that's ok. The volunteer will put no insurance and see if it goes through. If it goes through, you can bring your insurance card at the time of your appointment.

NOTE: We noticed that if you are not able to provide the medical insurance information, CVS requires us enter either your state's driver license number or your social security number in order for us to book the appointment. We personally don't feel comfortable taking your social security number. So, if you have driver's license of other form of government issued ID, we can use that try to book an appointment.

Medical Insurance Provider *

Member ID# *

Policy # *

Group ID# *

Relationship to Insurance Cardholder *

Self Spouse Child Other

Upload front and back of your insurance card *

Max file size: 20MB

Choice of Vaccination Site

Zip Code(s) and nearby location where you like to get your vaccine *

Driving Radius (in miles from specified zip code) *

Preferred Appointment Time *

Anything else the volunteer need to know... *

Submit

REQUIRED INFORMATION FOR BOOKING COVID VACCINE APPOINTMENT

Your Personal Information

Your Current Medical Status

Your Insurance Information

Choice of Vaccination Site

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