Fordland Clinic, Inc - Publicforms

Available Forms

DENTAL: New Adult Patient DENTAL: New Child Patient MEDICAL: New Adult Patient MEDICAL: New Child Patient Release of Information School COVID 19 Vaccine Pre-Registration

School COVID 19 Vaccine Pre-Registration

Instructions

Please complete all fields. There is an electronic signature for consent at the bottom of the form. If you feel a question does not apply to you/your child, please mark or type NA.

School: *

Please provide what public or private school you attend, or "homeschool". If you are an adult, just type NA.

First Name *

Last Name *

Date of Birth *

Address *

City *

State *

Zip *

County of Residence *

Sex *

Race *

Ethnicity *

Phone Number *

By providing my phone number, I opt-in to receive SMS messages from Fordland Clinic. SMS messages may take up to 20 minutes to arrive after submitting your information.

Email address *

COVID-19 Vaccine does not replace masking and social distancing guidelines to slow the spread of COVID-19. You will still need to do those things until your local, state, or federal guidance tells you otherwise.

Health Insurance Information

There is no charge for the vaccine. Insurance information is requested in order for the clinic to bill for nominal administration fees. If your insurance declines those, there is no cost to you.

Name of Insuror *

Insurance Policy Number/ID *

Insurance Group Number/ID *

My electronic or written signature on this form is my consent for Fordland Clinics, Inc. to administer the COVID vaccine to my age-eligible child. I have been informed that I am entitled to a written Notice of Privacy Practices, or I may find the Notice on the Fordland Clinic website, fordlandclinic.org.

Signature *

Please print and sign or type in your name and date of birth.

* Required field