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  • COVID-19 Vaccine Registration and Consent Form

  • Use this form in order to register and receive the Pfizer or Moderna vaccine. Visit this link (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations.html) for more information at the federal level. Visit this link (https://www.dshs.state.tx.us/coronavisus/immunize/vaccine.aspx) for more information at the state of Texas level. Visit this link for Pfizer emergency use authorization fact sheet (https://www.fda.gov/media/144414/download). Visit this link for Moderna emergency use authorization fact sheet (https://www.modernatx.com/covid19vaccine-eua/eua-fact-sheet-recipients.pdf).

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  • If you have insurance (Required if the patient has insurance. Information found on your card):

    Insurance Name:      

    Primary Insured Member Name:      

    Vaccine recipient relation to Primary Insured Member:      

    Primary Insured Date of Birth:   Pick a Date   

    Insurance Member ID:      

    Skip to the next question if you do NOT have insurance.

  • Clear
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  • Should be Empty: