Covid-19 Vaccination Form – Susquehana Valley Medical Specialties

COVID-19 Vaccination Application

Patient Name *

First

Middle

Last

Patient Date of Birth (mm/dd/yyyy) *

Gender *

Male
Female

Height (inches)

Selected Value: 0

Weight (lbs)

Selected Value: 0

Primary Care Physician *

Please list any medical conditions (if any)

Race *

Ethnicity *

Street Address *

City *

State *

Zip Code *

Primary Phone Number *

Primary Insurance Holder *

Group# *

Policy# *

By typing my name here, I authorize the release of any medical or other information with respect to this vaccine to my healthcare providers, Medicare, Medicaid, or other third party payer as needed and request payment of authorized benefits to be made on my behalf to SVMS. I fully understand that the Covid-19 vaccine is not FDA approved but has been given an emergency use authorization by the FDA to help prevent Covid-19 illness in individuals 18 years of age or older. I have had the opportunity to ask questions that were answered to my satisfaction and understand the benefits and risks of the vaccine. I consent to, or give consent for the administration of the vaccine. I fully release and discharge SVMS, its affiliates, officers, directors, and employees from any liability for illness, injury, loss, or damage which may result there from. *