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Patient Information Sheet

1. County I/we plan to attend a clinic in *This question is required.

Choose which clinic *This question is required.

2. Client Information

First Name *This question is required.

Middle Initial

Last Name *This question is required.

Maiden Name

Phone Number *This question is required.

Date of Birth *This question is required. This question requires a valid date format of MM/DD/YYYY.

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Patient Sex *This question is required.

Street Address *This question is required.

City *This question is required.

State *This question is required.

Zip *This question is required.

3. Patient Race/Ethnicity (please select all that apply) *This question is required.

American Indian/Alaskan Native
Asian
Black or African American
Hispanic or Latino/a/x
Middle Eastern or North African
Native Hawaiian or Pacific Islander
White
Prefer not to answer
Other - Write In (Required)

4. Insurance Status *This question is required.

Upload a photo of the front of your insurance card below.

If you are unable to upload proof of insurance, you must bring your card the day of clinic. If we do not have your insurance information the day of the appointment, you will be required to pay at that time or no vaccination will be administered.

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5. Would you like to register additional people in your household? *This question is required.

How many additional household members would you like to register? *This question is required.