School-Base Health Center Vaccination Form
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Schools Time Slot Vaccine Self Scheduling Consents HRSA Supplemental Table COC Request At Home Vaccinations Documents
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Vaccine Self Scheduling

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School-Base Health Center Vaccination Form

The following questions will help us determine if there is any reason your student should not get the Covid-19 vaccine.

If you answer “yes” to any question, it does not necessarily mean your child should not be vaccinated – it just means we may contact you with additional questions.

If a question is not clear, please call the School-Based Clinic provider noted in the introductory email.

School-Based Health Center Vaccination
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Select School or Clinic
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Optional
 
If you wish to be present with your student, do you prefer AM or PM?
   
If you wish to be present with your student, what is your preferred day of the week?
         
Patient Information
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Please enter your email address
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Phone Numbers Match
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Check all that apply to your student
 
 
 
 
 
 
 
 
 
 
 
 
 
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HRSA Data Collection
You are not required to provide any of the following but it is recommended.

Please note:
- Everyone can receive COVID-19 services, regardless of immigration status
- The information will be used for reimbursement purposes only
- The information will not be shared with immigration authorities
- No one will be turned away if they don't provide this information
- Testing, treatment, or vaccinations paid for by the federal government will not impact anyone's current or future immigration status

You will not billed for COVID-19 vaccine services
Insurance Details
Vaccine Attestation/Consent

Pfizer EUA

Please click on the link to review Pfizer Fact Sheet..

Moderna COVID-19 Vaccine EUA Fact Sheet for Recipients and Caregivers 08312022

Please click on the link to review Moderna COVID-19 Vaccine EUA..

EUA 27034_Fact Sheet for HCPs-Full EUA PI_Bivalent-Booster_Grey_final_8.31.2022

Please click on the link to review EUA 27034_Fact Sheet for HCPs-Full..

Moderna COVID-19 Vaccine HCP FS Gray 08312022

Please click on the link to review Moderna COVID-19 Vaccine HCP FS Gray..

Pediatric (5-11) Pfizer Fact Sheet

Please click on the link to review Pediatric (5-11) Pfizer Fact Sheet..

Recipients and Caregivers 12 years of age and older 08312022

Please click on the link to review Recipients and Caregivers 12 years of age and older..

CHC Privacy-Notice
I attest I am at least 18 years old or I am the parent or legal guardian of a patient who is 5 old years old or older.
* 
You will not be billed for COVID-19 vaccine services.

This box is only for patients receiving:

The Pfizer Vaccine primary series dosing for individuals 6 months to 11 years of age OR The Moderna Vaccine primary series dosing for 6 months to 17 years of age OR Dose 3 of the Pfizer Vaccine or Moderna Vaccine for individuals who are immunocompromised OR The Pfizer vaccine booster for individuals that are 5-11 years old that received their final dose of primary series 5 months ago or longer OR The Moderna Bivalent vaccine booster for individuals that are 18 years or older that received their final dose of primary series or any additional monovalent doses 2 months ago or longer OR The Pfizer Bivalent vaccine booster for individuals 12 years or older that received their final dose of a primary series or any additional monovalent dose 2 months ago or longer
* 
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OR
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Signer Details
By signing below I attest under penalty of perjury that I am 18 or older and consenting for myself or I am the legal guardian of the patient named below. I consent to receive or for my minor to receive the COVID-19 immunization.
 *  *
 *  *
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Please enter your email address
Phone Numbers Match
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