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.
Please provide what public or private school you attend, or "homeschool". If you are an adult, just type NA.
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.
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.
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.
Please print and sign or type in your name and date of birth.