Covid-19 Vaccination Request Form

Covid-19 Vaccine Request Form

Thank you for your interest in receiving the Moderna COVID-19 Vaccine. IVYDALE WELLNESS CENTER has been approved as a mass vaccination site. While we understand that allocation is currently limited, we will do our best to meet the needs of the community in order to help abate this pandemic.

Completion of your basic information below, which will be kept confidential per HIPAA policies, will help our staff set you up for an appointment. We will notify you of your scheduled vaccination date and time.

*You may complete this survey multiple times to include other household members. DO NOT include information for more than one person per survey.

Please bring photocopies of your health insurance card, (front and back, esp Medicare if applicable) AND valid photo ID (photocopy), to expedite the process. The state GRITS vaccine registry may require your SSN on the date of appointment. Only Admin Fee will be charged to your insurance to pay for the resources, supplies and staff. The vaccine is FREE. Other than sharing your information through the Georgia Vaccine Registry and the Georgia Department of Public Health, your information will not be sold or shared. It will only be used for the coordination of your COVID-19 vaccination.

Patient First Name *

Patient Last Name *

Email Address *

Phone *

Date of Birth *

Gender *MaleFemale

Home Address *Home Address

Language *EnglishSpanishOther

Ethnicity *Hispanic/Latino Non-Hispanic/Latino Declined to Specify

Do you have a Primary Care Physician/Provider? *YesNo

I am . . . (please choose all that apply) *65 years of age or older [Phase 1a] a healthcare worker (e.g., physician, nurse, medical staff, etc) [Phase 1a] a long-term care facility resident (nursing home/assisted living) [Phase 1a] a first responder (e.g., police, EMS, fire department) [Phase 1a] frontline essential worker (e.g., education, public transit, US Postal service, grocery store, corrections worker, manufacturing etc) [Phase 1b] an other essential worker (e.g., energy, finance, food service, IT/communication, construction, transportation, etc) [Phase 1c] ]a caregiver to an individual who is 65 years of age or older [Phase 1b/Phase 1a if applicable Other (please specify)

Other *

Allergies *

Primary Health Insurance Name (Medicare, if applicable) *

Primary Health Insurance Group# *

Primary Health Insurance Policy# *

Do you have a Secondary Health Insurance? *Yes (Please bring a photocopy on day of appointment) No

May we communicate your appointment by text or email? *Yes No

Declaration

"I, the undersigned patient, consent to the administration of COVID vaccine on the date of my appointment. I have provided Ivydale Wellness Center with the information needed to the best of my ability. I release Ivydale Wellness Center and its volunteers and employees from any liability relating to COVID Vaccine administration. I have read, fully understood and agreed to the above important information." (Patient name here as signature)

Signature *

OUR LOCATIONS

Georgia (GA)

361 resource Parkway

Winder, GA, 30680

We see patient virtually and in person.

Idaho

Ivydale wellness center LLC

9169 W State St #115

Garden City ID 83714

We see patient virtually only.

Oregon (OR)

8152 SW Hall Blvd, PMB 3044
Beaverton, OR 97008