COVID-19 Vaccine Interest Portal
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Vaccine
COVID-19 Vaccine Interest Portal
COVID-19 Vaccination Consent Form
First Name (Nombre):
*
Middle Name (Segundo Nombre):
Last Name (Apellido):
*
Date Of Birth (Fecha de Nacimiento):
*
Age should be 12 or older for Vaccination
Age (Edad):
0 years old
Sex (Sexo):
*
Select
Male
Female
Race (Raza):
*
Ethnicity (Etnicidad):
*
Mother First Name (Nombre de Madre):
*
Mother's Maiden Name:
*
Parent/Guardian Name:
*
Select Dose:
*
If you have already got your Dose 1 administered in Carrollton Regional Medical Center, you need not register again. You will have to Log into the Vaccine Portal with your user ID and PWD and select the Dose 2 slot as per the available schedules.
Last Dose Manufacturer:
*
Taken Date:
*
Vaccinated At:
Home Address
Address 1:
*
Address 2:
City:
*
State:
*
County Of Residence:
*
Country:
Zip Code:
*
Phone:
*
Email (User Name):
*
Password:
*
Confirm Password:
*
The above username and password should be used to log in to vaccine portal.
Screening Questions
Insurance Details
I have health insurance (including Medicare, Medicaid, or any other government funded benefit plan) and authorize CRMC to bill insurance for the immunization administration, with the understanding that I will not incur any cost.
I do not have health insurance.
Please enter your Insurance Member ID
Please enter your Insurance RxBIN
Please enter your Insurance RxGrp
Please enter your Insurance RxPCN
PLEASE BRING INSURANCE CARD TO YOUR APPOINTMENT, (if insured)
IF UNINSURED, BRING PROOF OF IDENTITY (Driver’s license, state issued ID card, Social Security Card, etc.)
Sign Below
I Agree, I hereby declare that all the given information are accurate.
Date :
Date :
First and Last Name
First and Last Name
Signature
*
clear
Parent/Guarding Signature
*
clear
Manufacturer
*
Register
