COVID-19 Vaccination Consent Form

0 years old

Home Address

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 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 :

First and Last Name
Signature*
Manufacturer*