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Indiana Department of Health: COVID-19 Vaccination Patient Intake Form
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* Indicates required question
Email
*
Your email
First Name of Dependent
*
Your answer
MI
Your answer
Last Name of Dependent
*
Your answer
Dependent Date of Birth (DOB)
*
MM
/
DD
/
YYYY
Gender
*
Female
Male
Prefer not to say
Other:
Mobile Phone Number
*
Your answer
Email Address
*
Your answer
Address
*
Your answer
CIty
*
Your answer
State
*
Choose
Indiana
Kentucky
Zip Code
*
Your answer
Preferred Language
*
English
Spanish
Other
Prefer not to say
Preferred Ethnicity
*
Hispanic or Latino/Spanish
Non-Hispanic or Latino/Spanish
Prefer not to say
Preferred Race
*
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific
White
Other:
Employer Name
Your answer
Primary Medical Insurance Carrier
Your answer
Policy Number
Your answer
Group ID
Your answer
Policy Holder
Your answer
Pregnant?
*
Yes
No
Is the patient sick today?
*
Yes
No
Does the patient have allergies to medications, food, a vaccine component, or latex?
*
Yes
No
Has the patient ever had a serious reaction after receiving a vaccination?
*
Yes
No
Risk Factors (Select ALL the apply)
*
Obesity
Over 65
Diabetes
Chronic Kidney Disease
COPD
Serious Heart Condition
Sickle Cell Disease
Other:
Required
Reason for Vaccination
Choose
Health Care Worker
Long Term Care Employee
Long Term Care Resident
Notice of Privacy Practices:
https://drive.google.com/file/d/1B_8INLHuSRUVNm0u96c4Ms5_8BvM1pn0/view?usp=sharing
The electronic signature below indicates that you have read the Notice of Privacy Practices.
Your answer
Patient/Parent Consent for COVID-19 Vaccination
*
The electronic signature below indicates your consent.
Your answer
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