1 of 5 Completed

Frequently Asked Questions

FAQs

How much does the vaccine cost?

There is no cost for COVID vaccination.

Which vaccine will be administered?

Based on availability we will be administering Moderna or Janssen (Johnson & Johnson's single-shot) vaccine.

What are common side effects?

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.

How many COVID-19 shots do I get?

• 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 .

Date of Birth (MM/DD/YYYY)

I am resident of

2 of 5 Completed

Patient Information

First Name

Last Name

Middle Initial

Address

State

City

Zip Code

Phone Number

Gender

Male	Female

For insured (proof of insurance required)	For uninsured

Please attach your insurance id(front) .jpg or .pdf should be more than 500KB or 300PI

Please attach your insurance id(Back) .jpg or .pdf should be more than 500KB or 300PI

Insurance Details

Insurance Company Name

Insurance Plan Name

Member/Subscriber ID

Group Number

Patient relationship to insured Member/Subscriber

Self	Spouse
Child	Other

3 of 5 Completed

Please attach your government issued id (front) .jpg or .pdf should be more than 500KB or 300PI

Please attach your government issued id(Back) .jpg or .pdf should be more than 500KB or 300PI

Issuing State

ID Type

ID Number

Patient Race (REQUIRED BY HHS AND CDC)

American Indian or Alaskan Native	Native Hawaiian or Other Pacific Islander(PI)	Asian(AS)
White	Black or African American(B)	Multiple/Other(O)

Patient Ethnicity

Hispanic/Latino(H)	Non Hispanic/Latino(N)
Asian(AS)

Marital Status

Single	Married
Domestic Partner	Separated
Divorced	Widowed

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

Do you have any of the following?

Have any severe allergies?	Yes	No
Have a fever?	Yes	No
Have a bleeding disorder or are on a blood thinner?	Yes	No
Are immuno compromised or are on a medicine that affects your immune system?	Yes	No
Are pregnant or plan to become pregnant?	Yes	No
Are breastfeeding?	Yes	No
Have received another COVID-19 vaccine?	Yes	No
Which Vaccine did you received?
Name Of Provider
Date Of First Dose
Are you a veteran?	Yes	No

Emergency Contact Name

Relationship to Patient

Emergency Contact Number

Work Phone #

4 of 5 Completed

Please read and e-sign the documents below

1	Immunizations Adult Consent Form	Read & Sign
2	ImmTrac2 Immunization Registry Disaster Information Retention Consent Form	Read & Sign

5 of 5 Completed

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.

BACK

COLOR OPTION

Covid-19 Vaccine Enrollment