Covid Vaccine and Booster Sign-up Form

Covid Vaccine and Booster Sign-up Form

Boosters are available to eligible populations. Please click here to see the CDC guidelines: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/booster-shot.html Please fill out this form to ensure SEARHC has all the necessary information for your upcoming visit.

Basic Request Information

With which request may we help you today?*

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What was the date of your last Covid-19 vaccine shot?*

Your last shot must be at least 2 months prior to today's date.

Which vaccine did you receive?*

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Which Vaccine would you like*

As soon as Moderna Updated Booster is available at SEARHC, it will be added as an option

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Vaccine you would like*

Select or enter value

Johnson & Johnson is currently not an option for Booster shots. Moderna or Pfizer are both approved options for all patients needing Boosters. Please contact your SEARHC clinic if you have concerns about your vaccine type.

Where did you receive your last vaccine?*

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In which location are you requesting treatment?*

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Are you an established SEARHC patient?*

Have you been seen at any SEARHC location for treatment before?

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Are you registered for the SEARHC Patient Portal*

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Would you like registration information?*

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Individual Patient Information

Please fill out this section to update your Patient Profile.

Last Name*

First Name*

Middle Initial

City and State of Birth*

Date of Birth*

Please type in date

What is your overall age group?*

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Father's Name

Required for all patients under 18 years of age.

Father's Date of Birth

Required for all patients under 18 years of age.

Father's Employer

Required for all patients under 18 years of age.

Father's Work Phone

Required for all patients under 18 years of age.

Mother's Name

Required for all patients under 18 years of age.

Mother's Date of Birth

Required for all patients under 18 years of age.

Mother's Employer

Required for all patients under 18 years of age.

Mother's Work Phone

Required for all patients under 18 years of age.

Patient's Social Security Number*

Other Names Used by Patient?

Demographic Information

This valuable information gives SEARHC the ability to provide the necessary care to all its patients.

Race*

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Ethnicity*

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Are you an IHS Beneficiary?*

The Indian Health Service (IHS) is a part of the federal government that delivers health care to American Indians and Alaska Natives (AI/ANs).

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What is your percentage of Native blood?*

This information is found on your 'Certificate of Indian Blood' card.

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What tribe do you belong to?*

Preferred Language*

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Do you require an interpreter?*

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Gender*

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Marital Status*

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Are you currently homeless?

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Please define your living situation

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How many people live in your household?

Do you have internet access?*

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What kind of internet connection(s) do you have?*

Choose all that apply.

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Are you a Veteran?*

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Contact Information

PO Box or Street Address*

City*

State, zip code*

Cell Phone*

Work Phone

Email*

Patient's Employer

Insurance Information

Primary Insurance Company*

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Insurance Name:*

Effective Date

Group #*

Policy #*

Policy Holder's Name*

Policy holder's DOB*

Dependent(s) Name

Do you have Secondary Insurance?*

Select

Secondary Insurance Company

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Insurance Name:

Effective Date

Policy #*

Group #*

Policy Holder's Name*

Policy Holder's DOB*

Dependent(s) Name

Emergency Contact Information

Emergency Contact Name*

Emergency Contact Phone #*

Emergency Contact Relationship*

Upload Documents

Please upload a photo of your identification, Insurance Card, and 'Certificate of Indian Blood' if applicable. Also please bring these documents to SEARHC for your appointment.

Drag and drop files here or

SECURE AND PROTECTED CONFIDENTIAL SITE

The CDC requirement has not been met.

Based off the date of your last vaccine you are not yet eligible for the Covid-19 Booster shot. Our team will contact you once you are eligible to schedule your visit. Respectfully, `The SEARHC Vaccination Team

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