Application name
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Essex Pharmacy & Surgical
1550 Country Ridge Ln
Essex, MD 21221
Phone :
410-686-0373
English
Español (Spanish)
Polski (Polish)
русский (Russian)
COVID-19 Vaccine Registration
Patient Information
First Name
Last Name
Date of Birth
Gender
Male
Female
Address 1
Address 2
City
State
Zip Code
County
Cell Phone
Home Phone
Email
Insurance Information
(Required if patient has insurance)
Insurance Name
Cardholder / Member ID
Rx BIN
Rx PCN
Group Number
Relation to Cardholder
Essex Pharmacy & Surgical
1550 Country Ridge Ln
Essex, MD 21221
Phone :
410-686-0373
English
Español (Spanish)
Polski (Polish)
русский (Russian)
COVID-19 Vaccine Registration
Guardian Information
(Optional Guardian Information)
Guardian First Name
Guardian Last Name
Date of Birth
Gender
Male
Female
Same as Patient Address?
Yes
No
Address 1
Address 2
City
State
Zip Code
Cell Phone
Relation to patient
Essex Pharmacy & Surgical
1550 Country Ridge Ln
Essex, MD 21221
Phone :
410-686-0373
COVID-19 Vaccine Registration
Other Information
Race
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Are you one of the following?
Essential Worker
?
I am a frontline essential worker (First Responder, Corrections, Food & Agriculture, Postal Service, Manufacturing, Grocery Store, Public Transit, Education) or I am staff or a participant of Adult Day Care.
First Responder
Healthcare Worker
?
I am a healthcare worker or home healthcare worker.
Person with chronic condition
Resident of a care facility or other group setting
?
I am a resident or staff at a long term care or congregate care facility.
I'm 65+
No, I am not any of the above
Do you have any pre-existing medical conditions?
?
I have a high risk medical condition (Obesity, Diabetes, Pulmonary disease, Heart condition including hypertension, Kidney disease, Cancer, Immunocompromised, Sickle cell, Pregnancy.
Yes
No
What dose of COVID-19 vaccine will this be?
First Dose
Second Dose
Booster Dose
Which COVID-19 vaccine did you receive previously?
Pfizer-BioNTech COVID-19 Vaccine
Moderna COVID-19 Vaccine
Janssen COVID-19 Vaccine
Date of previous dose
How may we contact you?
Email
Phone
Both
Essex Pharmacy & Surgical
1550 Country Ridge Ln
Essex, MD 21221
Phone :
410-686-0373
COVID-19 Vaccine Registration
Questionnaire
Essex Pharmacy & Surgical
1550 Country Ridge Ln
Essex, MD 21221
Phone :
410-686-0373
COVID-19 Vaccine Registration
Review Information
Appointment Date/Time
First Name
Last Name
Date of Birth
Gender
Address
County
Phone
Email
Guardian Information
Race
Ethnicity
Category
Medical Condition
Dose
Previous vaccine name
Date of previous dose
Contact Preference
I understand the benefits and risks of the COVID-19 vaccine as described in the
Emergency Use Authorization(EUA)
, which I have reviewed along with this Consent and Release.I understand that the pharmacy staff is available to answer any questions I may have and I can expect them to be answered to my satisfaction.I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent and Release.
I have reviewed the notice of
Privacy Practices
.I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy and of my rights with respect to my health information. I may discuss with the pharmacy staff any concerns I may have regarding the privacy of my health information.
I authorize the pharmacy to bill my insurance for the immunization.
Yes
No
Submit
Essex Pharmacy & Surgical
1550 Country Ridge Ln
Essex, MD 21221
Phone :
410-686-0373