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Covid-19 Vaccine Enrollment

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Frequently Asked Questions

FAQs

There is no cost for COVID vaccination.
Based on availability we will be administering Moderna or Janssen (Johnson & Johnson's single-shot) vaccine.
COVID-19 vaccination will help protect you from getting COVID-19. You may have some side effects, which are normal signs that your body is building protection. These side effects may affect your ability to do daily activities, but they should go away in a few days. CDC has published the common side effects, please visit https://www.cdc.gov/coronavirus/2019-ncov/vaccines/expect/after.html.
• For Moderna, there are two shots. After receiving the first shot, you will receive a follow-up email to book your second appointment for 28-42 days from the date of your first vaccine. Please do not leave from your first appointment until you receive confirmation.


Let's get you enrolled. For any questions regarding this form please email us at info@eixsys.org

Note:-
COVID-19 vaccines will only be given to those with scheduled appointments .




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Patient Information



Gender

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Patient Race (REQUIRED BY HHS AND CDC)

Patient Ethnicity

Marital Status


COVID-19 Clinical History (REQUIRED BY HHS and CDC)

Do you have any of the following?

Have any severe allergies?
Have a fever?
Have a bleeding disorder or are on a blood thinner?
Are immuno compromised or are on a medicine that affects your immune system?
Are pregnant or plan to become pregnant?
Are breastfeeding?
Have received another COVID-19 vaccine?
Are you a veteran?

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Please read and e-sign the documents below

1 Consent to Treat and Healthcare Agreement Read & Sign
2 Notice of Privacy Practices Read & Sign
3 Immunizations Adult Consent Form Read & Sign
4 ImmTrac2 Immunization Registry Disaster Information Retention Consent Form Read & Sign
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Thank you for your interest in receiving the COVID-19 vaccine during this current phase of distribution. After submitting your application, please check your email (Inbox/Spam folder). Your email will contain your confirmation number and information about scheduling your vaccination date.