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).
If you have insurance (Required if the patient has insurance. Information found on your card): Insurance Name: eg: Blue Cross Blue Shield Primary Insured Member Name: First Name Last Name Vaccine recipient relation to Primary Insured Member: e.g. spouse, child, self etc Primary Insured Date of Birth: MM-DD-YYYY Insurance Member ID: Skip to the next question if you do NOT have insurance.