STRIDE COVID Vaccine Registration (Short)

1
I do hereby give consent to diagnostic, treatment, counseling services from the clinical staff of STRIDE (Medical and Behavioral). I understand that there are certain hazards and risks connected with forms of treatment and my consent is given with this knowledge.* This field is required.
YESNO
2
I hereby acknowledge that I have reviewed the Notice of Privacy Practices and Patient Bill of Rights and Responsibilities on the STRIDE public website. Notice of Privacy Practices Patient Rights and Responsibilities
YESNO
3
Name of Patient Receiving the Vaccination* This field is required.
First Name
Last Name
4
Patient's date of birth (mm/dd/yyyy)* This field is required.
5
bday
Date
Year
Month
Day
6
Will the patient be over the age of 5 by the date of vaccination?
YESNO
7
I understand that a qualified medical professional will administer the COVID vaccination to my child. I will receive the EUA/ VIS for the vaccine administered to my child. I understand that STRIDE will rely on the information I provided above in order to determine if the vaccine can be safely administered to my child. The information I provided is correct. I am my child’s mother or father by birth or adoption, or my child’s court-appointed legal guardian and I have authority to consent to my child receiving the COVID vaccine.* This field is required.
I have read and understand the statement above.
8
The patient is being registered to receive:* This field is required.
1st dose
2nd dose
Booster
Pfizer Pediatric Dose Ages 5-11
9
Your phone number (mobile preferred)* This field is required.
10
Your email address
example@example.com
11
Your home address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
12
Have you been seen at STRIDE in the last 3 years?
YESNO
13
Do you have medical insurance?
YESNO
14
Patient is a minor - name of parent/guardian* This field is required.
First Name
Last Name
15
Patient is a minor - date of birth of parent/guardian* This field is required.
16
Patient is a minor - photo ID of parent/guardian
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
17
Photo ID (Driver’s License, State Issued ID, etc.)
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Select files to upload
Max. file size: 10.6MB
Cancelof
18
Medical Insurance Card (If applicable)Medical insurance is not required. If you do not have medical insurance or your medical insurance does not cover the vaccine you will not be billed.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
19
Verification Document (Badge from Qualifying Employer, Vaccine Eligibility Letter etc.)No verification document is required if you are qualifying based on age.
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Select files to upload
Max. file size: 10.6MB
Cancelof
20
We're sorry, at this time the COVID vaccine is not approved for patients under the age of 5. Please check back at a later date.
21
Individuals under the age of 12 are not currently recommended by the CDC to receive a vaccine booster.
22
This will end your registration.
23
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