COVID Registration
COVID Screening

COVID Registration

Thank you for your interest in signing up for the vaccine. The Governor has opened up the next phase of the process and the hospital and the health department received additional vaccines.

If you are 65 or older (O65) please call the health department (858-973-5000) to schedule an appointment and receive the vaccine.
If you are under the age of 65 (U65), we will contact you to validate your at-risk condition and schedule an appointment. If you selected one or more at-risk vulnerable condition, please click on the SCREENING tab to move to the next phase in the process.
You must have a confirmed appointment and supporting documentation to receive the vaccine.

Please be sure to follow us on Facebook @madisoncountymemorialhospitalmcmh or continue to check our website www.mcmh.us/covid to get the latest updates. If you do not use Facebook, we have created a Blog to communicate with the public regarding additional Vaccine activities. www.mcmh.us/blog.

Best regards,

Lori R. Evans

850-253-1961

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COVID 19 Registration for U65 Population

We received our second shipment of first dose vaccine. This phase is specifically for ages 18 to 64 with specific at-risk conditions. Please go to mcmh.us/blog for additional details.

Please complete this form as a first step in qualifying to get the Vaccine. A logistics coordinator will get back to you to process the remaining paperwork, validate your at-risk condition, and confirm your appointment.

ID Number (Hospital Use Only)

Is this your first or second dose of the COVID19 Vaccine?

First Dose

Second Dose

*Date of Birth

*First Name

*Middle Name

*Last Name

*Home or Work Phone Number

*Mobile Number

*Population Demographic-Stakeholder Group

Community Citizen OVER the Age of 65

Community Citizen UNDER the Age of 65

Provider Partner

Community Partner

Healthcare Worker

*Are you over the age of 65

Yes

*Are you under the age of 65 (U65) but have at-risk conditions?

Yes

*Do you have a FLORIDA address? You must show proof of homestead for FLORIDA or have a FLORIDA Driver's License.

Yes

Street Address

City

Zip Code

Gender Assigned at Birth

Male

Female

Ethnicity

Hispanic or Latino

Not Hispanic or Latino

Unknown

Race

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or other Pacific Islander

Other Nonwhite

White

Unknown

Physicians Name

How Did You Hear About MCMH Doing the Vaccine?

Are you considered vulnerable?Please select all that apply below:

Yes

Are you clinically "EXTREMELY VULNERABLE"? (please check all that apply)

Asthma (moderate-to-severe)

Cancer

Cerebrovascular disease (affects blood vessels and blood supply to the brain)

Chronic kidney disease

COPD (chronic obstructive pulmonary disease)

Cystic fibrosis

Down Syndrome

Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies

Hypertension or high blood pressure

Immunocompromised state (weakened immune system) from solid organ transplant

Immunocompromised state (weakened immune system) from blood or bone marrow transplant, immune deficiencies, HIV, use of corticosteroids, or use of other immune weakening medicines

Liver disease

Neurologic conditions, such as dementia

Obesity (body mass index [BMI] of 30 kg/m2 or higher but < 40 kg/m2)

Overweight (BMI > 25 kg/m2, but < 30 kg/m2)

Pulmonary fibrosis (having damaged or scarred lung tissues)

Pregnancy

Severe Obesity (BMI ≥ 40 kg/m2)

Sickle cell disease

Thalassemia (a type of blood disorder)

Type 1 diabetes mellitus

Type 2 diabetes mellitus

Other

Other "VULNERABLE" condition:

Please select the best day to schedule your appointment

Tuesday

Thursday

Please select the best time of the day

Employer (this information is used primarily to assess large numbers of people at the same location who wish to receive the vaccine)

Please share any specific concerns your feel are pertinent for receiving the vaccine.

File Upload (click to upload supporting documentation-insurance card, at-risk conditions, etc.)

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Type Your First, Middle, and Last Name to Acknowledge a Signature for the Person Receiving the Vaccine:

Click YES to Give Consent and click SUBMIT to finish.

*Yes I Give Consent for the Hospital to Contact Me.

Yes

*I Understand & Certify (place a check before each bullet)

•I understand I must bring supporting documentation (an upload button is provided above for your convenience or bring papers to your vaccination appointment).

•If part-time resident in Florida I understand I must show proof of HOMESTEAD with mine and/or my spouses name or have a FLORIDA Driver's License.

•For at-risk conditions I understand I must provide one of the following: 1) current prescription; 2) diagnosis and/or care plan; or 3) Physician/Provider Letter of Recommendation AND a picture ID.

•I understand I must provide proof of insurance if applicable.

COVID Screening

Thank you for your interest in signing up for the vaccine. The Governor has opened up the next phase of the process and the hospital and the health department received additional vaccines. If you are 65 or older (O65) please call the health department (858-973-5000) to schedule an appointment and receive the vaccine. If you are under the age of 65 (U65), we will contact you to validate your at-risk condition and schedule an appointment.

<br>Please be sure to follow us on Facebook @madisoncountymemorialhospitalmcmh or continue to check our website www.mcmh.us/covid to get the latest updates. If you do not use Facebook, we have created a Blog to communicate with the public regarding additional Vaccine activities. www.mcmh.us/blog.

<br>Best regards,

Lori R. Evans

850-253-1961

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COVID 19 Vaccination Screening Form

We received our second shipment of first vaccine doses. This phase is designed to serve ages 18 to 64 with specific at-risk conditions. Once you complete the REGISTRATION FORM, you need to complete this VACCINATION SCREENING form. Once both forms are complete and a logistics coordinator validates your condition, you are ready for your scheduled vaccination appointment.

If you did not fill out the REGISTRATION FORM, please go to http://www.mcmh.us/forms and click REGISTER to complete the form as a first step in getting the Vaccine. A logistics coordinator will get back to you to conduct the screening process, validate your at-risk condition, and confirm your appointment.

ID Number (Hospital Use Only)

*First Dose or Second Dose

First

Second

*Date of Birth

*First Name

*Middle Name

*Last Name

*Home or Work Phone Number

*Mobile Number

Additional Phone Number

Section 2 - Insurance

Primary Insurance

Insurance Company Phone:

Primary Insurance Carrier ID:

Group ID:

Insured’s Name:

Relationship to Insured:

Insured’s Date of Birth:

Secondary Insurance:

Please share any specific concerns your feel pertinent for receiving the vaccine.

Section 3: COVID19 SCREENING

PLEASE CHECK YES OR NO FOR EACH QUESTION

*1. Are you sick today?

Yes

*2. Have you had a severe allergic reaction to a previous dose of this vaccine or to any of the ingredients of this vaccine?

Yes

*3. Do you carry an Epi-pen for emergency treatment of anaphylaxis?

Yes

*4. For women, are you pregnant or is there a chance you could become pregnant?

Yes

*5. For women, are you breastfeeding?

Yes

*6. Have you had any other vaccinations in the previous 14 days?

Yes

*7. In the past two weeks, have you tested positive for COVID-19?

Yes

*8. Have you had in the last 10 days fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea, vomiting, or diarrhea?

Yes

*9. Do you have allergies or reactions to any medications, foods, vaccines, or latex? Please explain:

Yes

*10. are you immunocompromised/on medicine that affects immune system?

Yes

*11. Do you have a bleeding disorder or are you on a blood thinner/blood-thinning medication?

Yes

*12. Have you received a previous dose of any COVID-19 vaccine? If yes, which manufacturer’s vaccine did you receive:

Yes

COVID19 Vaccine Type:

*Qualifying Vulnerable Condition: (please select all that apply)

Other "VULNERABLE" condition:

File Upload (click to upload supporting documentation-insurance card, ID, etc.)

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Multi-Upload Prescriptions OR Dr. Letter of Recommendation

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Click YES to give consent, Type your full name, and click SUBMIT to finish.

*Yes I Give Consent for the Hospital to Contact Me.

Yes

*Type your first middle and last name as signature for receiving the vaccine:

Section 4: Certification & Authorization Statement

*Date of Signature Authorization

*Certification & Authorization Statement (Place a check mark by each bullet)

•I certify that I am: (a) the patient and at least 18 years of age; (b) the legal guardian of the patient and confirm that the patient is at least 18 years of age; or (c) authorized to consent for vaccination for the patient named above. Further, I hereby give my consent to Madison County Memorial Hospital (MCMH) or its agents to administer the COVID-19 vaccine.

•I understand that this product has not been approved or licensed by FDA, but has been authorized for emergency use by FDA, under an EUA to prevent Coronavirus Disease 2019 (COVID-19) for use in individuals 18 years of age and older; and the emergency use of this product is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of the medical product under Section 564(b)(1) of the FD&C Act unless the declaration is terminated or authorization revoked sooner.

•I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccine(s). I understand the risks and benefits associated with the above vaccine and have received, read and/or had explained to me the Emergency Use Authorization Fact Sheet on the COVID-19 vaccine I have elected to receive. I also acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction.

•I acknowledge that I have been advised to remain near the vaccination location for approximately 15 minutes after administration for observation. If I experience a severe reaction, I will call 9-1-1 or go to the nearest hospital.

•On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless the State of Florida, the Florida Department of Health (DOH), Madison County Memorial Hospital and their staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the vaccine listed above.

•I acknowledge that: (a) I understand the purposes/benefits of Florida SHOTS, Florida’s immunization registry and (b) MCMH will include my personal immunization information in Florida SHOTS and my personal immunization information will be shared with the Centers for Disease Control (CDC) or other federal agencies.

•I further authorize MCMH or its agents to submit a claim to my insurance provider or Medicare Part B without supplemental coverage payment for me for the above requested items and services. I assign and request payment of authorized benefits be made on my behalf to MCMH or its agents with respect to the above requested items and services. I understand that any payment for which I am financially responsible is due at the time of service or if MCMH invoices me after the time of service, upon receipt of such invoice.

•I acknowledge receipt of the Notice of Privacy Rights.

DO NOT WRITE BELOW THIS LINE

Entered By:

Date Vaccine Appointment