Patient Vaccine Registration - MD Whitest Medical Institute

Pre-Registration Checklist - Step 1 of 12

Appointment type

Moderna COVID-19 Vaccine
Vaccine manufacturer may very based on availability

Choose your appointment availability *

i.e. How many days or weeks out before you are able to schedule your appointment?

Who's this appointment for?

Name *

First

Last

Date of Birth (mm/dd/yyyy) *

example: 02/17/1972

Gender *

Male
Female

Demographics

Race *

CDC requires us to capture this information for Covid vaccine administration.

How do we get in touch?

We will only reach out if we have any questions.

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number *

Primary care physician

Does this person have a primary care physician? *

Eligibility to receive COVID-19 vaccine in Georgia

Confirm you belong to of these groups:

Checkboxes *

Individuals who are 16 years of age or older

Last update 04/13/21

1. Allergies *

Do you have any allergies to any contents in this vaccine, which includes polyethylene.
Glycol (PEG) OR to polysorbate

2. Wellness *

Are you sick or injured today?
Examples: A new or moderate to high fever, cough, diarrhea, vomiting, cut, injury, puncture or open wound that prompted you to get a tetanus shot

3. Health *

In the past two weeks, have you tested positive for COVID-19 or have you currently been exposed to someone with COVID-19? (for healthcare personnel have you had a high-risk exposure for which you been recommended to quarantine.

4. Previous vaccine reactions *

Do any of the following apply to you?
Had a reaction, fainted, or felt dizzy after receiving a vaccine
Healthcare professional has cautioned you about receiving certain vaccines
Healthcare professional has warned you about receiving vaccines outside of a medical setting

5. Blood Thinner *

Do you have a bleeding disorder or are you on a blood thinner?

6. Pregnancy *

Do any of the following apply to you?
Currently pregnant
Considering becoming pregnant in the next month
Breast-feeding

7. Immune system *

Are you immunocompromised or on any medication that affect your immune system?

8. Vaccine or Skin Test? *

Have you received any vaccinations or skin tests in the past four weeks?

9. COVID-19 *

Have you had any vaccinations in the past 14 Days?

10. Recent Injections *

If you were with COVID-19 in the past 90 days did you receive antibody therapy or convalescent plasma for treatment of COVID illness?

Acknowledgement

I was provided the Fact Sheet for Recipients for the COVID-19 vaccine I am receiving I read and/or had explained to me the information provided about the vaccine. I was given the chance to ask questions and any questions I had were answered to my satisfaction. I understand the risks and benefits of the vaccination and I am voluntarily choosing to get the vaccination.

I understand I should remain in the vaccine administration area 15 minutes after the vaccination to be monitored for any potential adverse reactions. If I have had a previous severe reaction to a vaccine, I will be monitored for 30 minutes I understand if I experience any side effects after leaving the vaccination site or if the side effects are severe. I should call 911.

Authorization For Payment

I authorize release of my personal, billing, and medical information to third party payers, insurance companies review agencies. for use in connection with payment, including eligibility for payment, regulatory accreditation compliance or as is required for provider to receive payment or reimbursement for care. I authorize and irrevocably assign to the administrator of the vaccine payment of any benefits payable to Mel amounts payable for the vaccine I receive.

Disclosure of Records

I understand M D Whitest Medical Institute may be required to or may voluntarily disclose my health information to the physician responsible for this protocol of specific health information of people vaccinated by M D Whitest Medical Institute, my Primary Care Physician (If have one), my insurance plan, health systems and hospitals, and/or state/federal registers, for purposes of treatment, payment or other health care operations. I also understand that M D Whitest Medical Institute will use and disclose my health information as set forth in the ministry Notice of Privacy practices (a copy is available upon request).

I agree that The M D Whitest Medical Institute and its business associates may contact me by any phone number provided by me or associated with my health including cell phone numbers, which could result in charges to me. M D Whitest Medical Institute also may contact by sending text messages or mails, using information provide. Methods of contact may in dude using pre-recorded/artificial voice messages and/or use of an automatic dialing device. I agree for my photo to be take and used for promotional if agreed.

Acknowledgement of notice receipt

I acknowledge receipt of Privacy Notices *

Decline
I acknowledge

I acknowledge receipt of M D Whitest Medical Institute Health & Wellness Notices. I understand that the Notice is subject to change. Refusing to acknowledge receipt will have no impact on my treatment.