Rachit Drugs : COVID-19 Vaccine Registration Form

COVID-19 Vaccine Registration Form

Vaccine Appointment Information

State *

Pharmacy Name *

Vaccination Rollout Category*

Vaccine Manufacturer

Are you Healthcare Worker?

Date of Birth (YYYYMMDD) *

Date *

Personal information

Have you taken your COVID first dose?

Facility Address State

Facility Address Zip Code

Patient's First Name *

Patient's Middle Name

Patient's Last Name *

Patient's Email *

Patient's Phone Number *

Phone number mobile?

Yes

Service Provider *

Gender *

Race *

Ethnicity *

Address Line1*

Address Line2 (Apt/Unit/Suite)

City *

State *

County

Zip Code *

Address Type *

Emergency Contact Name

Emergency Contact Number

Person’s Relationship

Primary Care Doctor

Doctor’s Number

Doctor’s Address Line 1

Doctor’s Address Line 2 (Apt/Unit/Suite)

Doctor’s Address City

Doctor’s Address State

Doctor’s Address Zip Code

List Medical Conditions

Insurance And Identification Information

Note: You can upload maximum 4 images and please upload valid JPG, JPEG or PNG image format with recommended dimension 900X675

Type of Identification *

Do you have insurance?

You have to add only Medicare Insurance Member/Recipient ID or Insurance Plan Name & Member/Recipient ID of Pharmacy Insurance & Medical Insurance.

Information Type

Pharmacy Insurance

Medical Insurance

Medicare Insurance

Are you the cardholder? Yes No

We aim to lead in each practice and area of law we work in. Coming from in-depth understanding of the law.

27 Division St, New York, NY 10002 United States

Phone:

8 800 2534 236

Send Email:

email@example.com

COVID-19 Vaccine Registration Form

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