Covid Vaccine Request

Name*

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Screening

Are you a healthcare worker? A teacher? Childcare or essential service provider?*

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Are you 65 or over? (Category/Phase 1B)*

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Are you 16 or older with at least one of the following chronic conditions?*

cancer, chronic kidney disease, COPD, heart conditions, coronary artery disease or cardiomyopathy, solid organ transplantation, obesity, pregnant, sickle cell disease, type 2 diabetes mellitus

Are you a student / Live in crowded housing / Homeless*

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Do you have an allergic reaction to any vaccine?*

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Do you feel sick today?*

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Have you experienced any of the following symptoms within 10 days?*

fever, chills, shortness of breath, fatigue, muscle or body ache, loss of taste or smell

Have you had a positive COVID-19 test within 14 days?*

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Did you receive a previous dose of any COVID-19 vaccine?*

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

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Are you immunocompromised or on a medicine that affects your immune system?*

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Allergic Reaction

Have you ever had an allergic reaction to: (This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.)

A component of a COVID-19 vaccine including either of the following:

Allergic Reactions

Select All
Polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures
Polysorbate, which is found in some vaccines, film coated tablets, and intravenous steroids.
A previous dose of COVID-19 vaccine.
A vaccine or injectable therapy that contains multiple components, one of which is a COVID-19 vaccine component, but it is not known which component elicited the immediate reaction.

Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?*

Yes
No

(This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.)

Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a component of COVID-19 vaccine, or any vaccine or injectable medication? This would include food, pet, venom, environmental, or oral medication allergies.*

Yes
No

Have you received any vaccine in the last 14 days?*

Yes
No

Have you ever had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?

Yes
No

Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?*

Yes
No

Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?*

Yes
No

Do you have a bleeding disorder or are you taking a blood thinner?*

Yes
No

Are you pregnant or breastfeeding?*

Yes
No

Do you have dermal fillers?*

Yes
No

For Insurance Purposes

Name of Insurance Company*

Insurance ID*

Email*

Social Security #*

Address

Phone Number To Reach You by SMS (Text message)*

Date of Birth*

Age*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Race

Ethnicity

Gender

Vaccine Scheduling & Location

Choose if you are able to arrive at PrimeCare Facility or if you need our team to help service your business or school

Location Request

Onsite Location Request

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date Requested

Arrival Time Requested

: HH

MM

What vaccine are you recieving?

Which vaccine product did you recieve?

Service

Location

Pick Date For Service

June 2021

Sun	Mon	Tue	Wed	Thu	Fri	Sat
		1	2	3	4	5
6	7	8	9	10	11	12
13	14	15	16	17	18	19
20	21	22	23	24	25	26
27	28	29	30

June 25, 2021

June 26, 2021

June 29, 2021

June 30, 2021

Click For Driving Directions

611 W MAIN ST
ARLINGTON, TX 76010-1008

Questions, call 817-996-1092

Consent*

I agree to the privacy policy.

By signing below, I hereby agree that the information I have given in this form is accurate and complete. I will receive COVID19 vaccine. I release and discharge all the employees, administrators, agents and governmental bodies from any and all claims.

Signature*

National COVID-19 task force, Register for Covid Vaccine!

Covid Vaccines | CDC Request

Screening

Allergic Reaction

A component of a COVID-19 vaccine including either of the following:

For Insurance Purposes

Address

Vaccine Scheduling & Location

Choose if you are able to arrive at PrimeCare Facility or if you need our team to help service your business or school

June 2021

June 25, 2021

June 26, 2021

June 29, 2021

June 30, 2021

Click For Driving Directions

611 W MAIN ST
ARLINGTON, TX 76010-1008

National COVID-19 task force, Register for Covid Vaccine!

Covid Vaccines | CDC Request

Screening

Allergic Reaction

A component of a COVID-19 vaccine including either of the following:

For Insurance Purposes

Address

Vaccine Scheduling & Location

Choose if you are able to arrive at PrimeCare Facility or if you need our team to help service your business or school

June 2021

June 25, 2021

June 26, 2021

June 29, 2021

June 30, 2021

Click For Driving Directions

611 W MAIN ST ARLINGTON, TX 76010-1008

611 W MAIN ST
ARLINGTON, TX 76010-1008