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Please review the latest updates and vaccination priorities and parameters at mcmh.us/covid.
Please complete the REGISTRATION FORM first.
If you check one or more of the vulnerable conditions, please complete the SCREENING FORM second.
A logistics coordinator will get back to you to validate your condition and collect supporting documentation for the clinical team.
Once you qualify to receive the vaccine a logistics coordinator will CONFIRM your appointment.
You MUST have an appointment to receive a vaccine and all supporting documentation must be provided prior to vaccination. An upload link is provided for your convenience or you can bring a printed copy with you to your appointment.
If you did not select one or more qualifying conditions you will be added to the waiting list and our team will contact you as the Governor continues to open the vaccine up to different demographic groups.

Drive Through
Employer Sponsored

Drive Through

Please click the registration form below to schedule a drive through appointment at the hospital lobby pavilion.

Thank you for your interest in signing up for the vaccine. The Governor has opened up the final phase to allow all Florida residents ages 18 and older without underlying health issue get the vaccine. Bring a picture ID, insurance card if applicable, and proof of Florida residency. Pull to the front of the hospital and remain in your vehicle the entire time. Please be sure to follow us on Facebook @madisoncountymemorialhospitalmcmh or continue to check our website www.mcmh.us/covid to get the latest updates. Please share with your circle of family and friends go to mcmh.us/covid-vaccine to sign up. 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 Vaccination Screening & Registration Form

The Governor has opened up vaccines to anyone over the age of 18 as of April 5th. The form below serves as a screening and registration form for anyone in that age bracket. Please complete this form to register for a drive through appointment at the hospital and a logistics coordinator will confirm a day and time for you to join us at the drive through Vaccination Station at the front lobby pavilion.

ID Number (Hospital Use Only)

Entered by (hospital use only)

*First Dose or Second Dose

First

Second

*First Name

*Middle Name

*Last Name

*Date of Birth

*Primary Care Physician

*Demographic Group

OVER THE AGE OF 65

OVER THE AGE OF 40

OVER THE AGE OF 18

18 to 65+ with at-risk condition

Healthcare worker

*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

*Home or Work Phone Number

*Mobile Number

Additional Phone Number

*Email

Address

City

Zip Code

County

Section 2 - Insurance

Primary Insurance

Other Insurance if applicable

Insurance Company Phone:

Primary Insurance Carrier ID:

Group ID:

Insured’s Name:

Relationship to Insured:

Insured’s Date of Birth:

*Employer

Section 3: COVID19 SCREENING

PLEASE CHECK YES OR NO FOR EACH QUESTION BELOW. ARE YOU OR HAVE YOU EVER...

*1. Are you sick today?

Yes

*2. Had an allergic reaction to previous dose of vaccine or ingredients of?

Yes

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

Yes

*4. 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. 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. Have allergies or reactions to medications, foods, vaccines, or latex?

Yes

*10. Are you immuno compromised on medicine that affects immune system?

Yes

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

Yes

*12. Had a previous dose of COVID-19 vaccine? which manufacturer?

Yes

COVID19 Vaccine Type:

*Qualifying Vulnerable Condition: (select all)

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

*Preferred Day for Vaccine Appointment

*Time

Click YES to give consent and click SUBMIT to finish.

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

Yes

*First middle and last name as signature:

*Date of Signature Authorization

Section 4: Certification & Authorization Statement

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

•I understand I must live in Florida and provide a picture ID and Insurance if applicable.

•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.

<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. Please share with your circle of family and friends go to mcmh.us/covid-vaccine to sign up. 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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Formulario de registro y detección de vacunación COVID 19

El gobernador ha abierto las vacunas a cualquier persona mayor de 18 años a partir del 5 de abril. El siguiente formulario sirve como formulario de evaluación y registro para cualquier persona de ese grupo de edad. Complete este formulario para registrarse para una cita y un coordinador de logística confirmará el día y la hora para que se una a nosotros en el recorrido a través de la estación de vacunación.

ID Number (Hospital Use Only)

*Primera dosis o segunda dosis

* Primer nombre

*Segundo nombre

*Apellido

*Fecha de cumpleaños

*Médico de atención primaria

*Grupo demográfico

MAYORES DE 65 AÑOS

MAYORES DE 40 AÑOS

MAYORES DE 18 AÑOS

18 a 65+ con condición de riesgo

Trabajador de la salud

*Sexo asignado al nacer

*Etnicidad

Hispano o Latino

No Hispano o Latino

Desconocido

*Raza

Indio americano o nativo de Alaska

Asiático

Negro o Afroamericano

Nativo de Hawai u otra isla del Pacífico

Otro no blanco

Blanco

Desconocido

*Número de teléfono de casa o trabajo

*Número de teléfono móvil

Número de teléfono adicional

*Email

*Dirección

*Ciudad

*Código postal

County

Sección 2 - Seguro

Seguro primario

Otro seguro si corresponde

Teléfono de la compañía de seguros:

Identificación de la compañía de seguros principal:

Identificación del grupo:

Nombre del asegurado:

Relación con el Asegurado:

Fecha de nacimiento del asegurado:

*Empleador

Sección 3: EXAMEN COVID19

POR FAVOR MARQUE SÍ O NO PARA CADA PREGUNTA A CONTINUACIÓN. ES USTED O HA USTED alguna vez ...

*1. ¿Estas enfermo hoy?

sí

*2. Ha tenido una reacción alérgica a una dosis anterior de vacuna o ingredientes.

sí

*3. ¿Lleva un Epi-pen para el tratamiento de emergencia de la anafilaxia?

sí

*4. Mujeres, ¿está embarazada o existe la posibilidad de que pueda quedar embarazada?

sí

*5. Para las mujeres, ¿está amamantando?

sí

*6. ¿Ha recibido otras vacunas en los últimos 14 días?

sí

*7. En las últimas dos semanas, ¿dio positivo por COVID-19?

sí

*8. en los últimos 10 días: fiebre, escalofríos, tos, falta de aire, dificultad para respirar, fatiga, dolores musculares o corporales, dolor de cabeza, nueva pérdida del gusto u olfato, dolor de garganta, congestión o secreción nasal, náuseas, vómitos o diarrea.

sí

*9. ¿Tiene alergias o reacciones a medicamentos, alimentos, vacunas o látex?

sí

*10. ¿Está usted inmunocomprometido con medicamentos que afectan el sistema inmunológico?

sí

*11. ¿Tiene un trastorno hemorrágico o está tomando un medicamento anticoagulante?

sí

*12. ¿Recibió una dosis anterior de la vacuna COVID-19? cual fabricante?

sí

Tipo de vacuna COVID19:

*Condición vulnerable calificada: (seleccionar todo)

Comparta cualquier inquietud específica que considere pertinente para recibir la vacuna.

*Día preferido para la cita de la vacuna

*Tiempo

Haga clic en SÍ para dar su consentimiento y haga clic en ENVIAR para finalizar.

*Sí, doy mi consentimiento para que el hospital se comunique conmigo.

sí

*Primer segundo nombre y apellido como firma:

*Fecha de autorización de firma

Sección 4: Declaración de certificación y autorización

*Declaración de certificación y autorización (coloque una marca de verificación junto a cada viñeta)

•Entiendo que debo vivir en Florida y proporcionar una identificación con foto y seguro si corresponde.

•Certifico que soy: (a) el paciente y al menos 18 años de edad; (b) el tutor legal del paciente y confirmar que el paciente tiene al menos 18 años de edad; o (c) autorizado para dar su consentimiento para la vacunación del paciente mencionado anteriormente. Además, por la presente doy mi consentimiento al Madison County Memorial Hospital (MCMH) o sus agentes para administrar la vacuna COVID-19.

• Entiendo que este producto no ha sido aprobado ni autorizado por la FDA, pero ha sido autorizado para uso de emergencia por la FDA, bajo una EUA para prevenir la Enfermedad por Coronavirus 2019 (COVID-19) para uso en individuos 18 años de edad y mayores; y el uso de emergencia de este producto solo está autorizado mientras dure la declaración de que existen circunstancias que justifiquen la autorización del uso de emergencia del producto médico bajo la Sección 564 (b) (1) de la Ley FD & C, a menos que la declaración sea terminada o autorización revocada antes.• Entiendo que este producto no ha sido aprobado ni autorizado por la FDA, pero ha sido autorizado para uso de emergencia por la FDA, bajo una EUA para prevenir la Enfermedad por Coronavirus 2019 (COVID-19) para uso en individuos 18 años de edad y mayores; y el uso de emergencia de este producto solo está autorizado mientras dure la declaración de que existen circunstancias que justifiquen la autorización del uso de emergencia del producto médico bajo la Sección 564 (b) (1) de la Ley FD & C, a menos que la declaración sea terminada o autorización revocada antes.

•Entiendo que no es posible predecir todos los posibles efectos secundarios o complicaciones asociadas con recibir la (s) vacuna (s). Entiendo los riesgos y beneficios asociados con la vacuna anterior y he recibido, leído y / o me han explicado la Hoja de datos de autorización de uso de emergencia sobre la vacuna COVID-19 que elegí recibir. También reconozco que he tenido la oportunidad de hacer preguntas y que tales preguntas fueron respondidas a mi satisfacción.

• Reconozco que me han aconsejado que permanezca cerca del lugar de vacunación durante aproximadamente 15 minutos después de la administración para observación. Si experimento una reacción grave, llamaré al 9-1-1 o iré al hospital más cercano.

•En nombre mío, de mis herederos y representantes personales, por la presente libero y eximo al Estado de Florida, al Departamento de Salud de Florida (DOH), al Hospital Memorial del Condado de Madison y a su personal, agentes, sucesores, divisiones, afiliados, subsidiarias y funcionarios. , directores, contratistas y empleados de todas y cada una de las responsabilidades o reclamaciones, ya sean conocidas o desconocidas, que surjan de, en conexión con o de alguna manera relacionada con la administración de la vacuna mencionada anteriormente.

• Reconozco que: (a) Entiendo los propósitos / beneficios de Florida SHOTS, el registro de vacunación de Florida y (b) MCMH incluirá mi información de vacunación personal en Florida SHOTS y mi información de vacunación personal será compartida con los Centros para Control de Enfermedades (CDC) u otras agencias federales.

• Además, autorizo a MCMH o sus agentes a presentar un reclamo a mi proveedor de seguros o la Parte B de Medicare sin el pago de cobertura complementaria para mí por los artículos y servicios solicitados anteriormente. Asigno y solicito que el pago de los beneficios autorizados se realice en mi nombre a MCMH o sus agentes con respecto a los artículos y servicios solicitados anteriormente. Entiendo que cualquier pago por el cual soy financieramente responsable vence al momento del servicio o si MCMH me factura después del tiempo del servicio, al recibir dicha factura.

•Acuso recibo del Aviso de derechos de privacidad.

Employer Sponsored

Please click the registration form below to schedule a mobile vaccination appointment at an employer sponsored event.

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COVID 19 Vaccination Mobile Screening & Registration

Your employer has provided you the opportunity to receive the vaccine at work. The form below serves as a screening and registration form for anyone who is interested in booking a mobile vaccination appointment. Requirements: over the age of 18, a copy of an insurance card (if you have insurance), and a picture ID verifying you are a Florida Resident.

ID Number (Hospital Use Only)

Entered by (hospital use only)

*First Dose or Second Dose

First

Second

*First Name

*Middle Name

*Last Name

*Date of Birth

*Primary Care Physician

*Demographic Group

OVER THE AGE OF 65

OVER THE AGE OF 40

OVER THE AGE OF 18

18 to 65+ with at-risk condition

Healthcare worker

*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

*Home or Work Phone Number

*Mobile Number

Additional Phone Number

*Email

*Address

*City

*Zip Code

County

Section 2 - Insurance

Primary Insurance

Other Insurance if applicable

Insurance Company Phone:

Primary Insurance Carrier ID:

Group ID:

Insured’s Name:

Relationship to Insured:

Insured’s Date of Birth:

*Employer

Section 3: COVID19 SCREENING

PLEASE CHECK YES OR NO FOR EACH QUESTION BELOW. ARE YOU OR HAVE YOU EVER...

*1. Are you sick today?

Yes

*2. Had an allergic reaction to previous dose of vaccine or ingredients of?

Yes

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

Yes

*4. 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

*9. Have allergies or reactions to medications, foods, vaccines, or latex?

Yes

*10. Are you immuno compromised on medicine that affects immune system?

Yes

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

Yes

*12. Had a previous dose of COVID-19 vaccine? which manufacturer?

Yes

COVID19 Vaccine Type:

*Qualifying Vulnerable Condition: (select all)

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

*Preferred Day for Vaccine Appointment

*Time

Click YES to give consent and click SUBMIT to finish.

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

Yes

*First middle and last name as signature:

*Date of Signature Authorization

Section 4: Certification & Authorization Statement

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

•I understand I must live in Florida and provide a picture ID and Insurance if applicable.

•I acknowledge receipt of the Notice of Privacy Rights.

Upload supporting documentation (Picture ID and Insurance Card)

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MCMH

224 NW Crane Avenue
Madison, FL 32340

(850) 973-2271

Family. Faith. History.

The provider of the best family-centered health care in our region.

Mission

To enhance the quality of life by continuously improving the health of the people of our community