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.
Please list current health insurance information if you are insured. Include name of Company, Policy Number and Group Number.
We do not bill for the vaccine, but will submit an administration fee. There is no cost to you if uninsured or insurance does not cover.
The above information will be used to contact you when COVID-19 Vaccine is available per Missouri Phased Guidelines. Please do not pre-Register more than once, as this will slow the process in notifying patients of vaccine availability.
Please Note: 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.
*As defined by your state guidelines
My electronic or written signature on this form is my consent for Fordland Clinics, Inc. to administer the COVID vaccine. 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.
Please print and sign or type in your name and date of birth.