Long Beach Island COVID-19 Vaccination Registration
Registration Form
Address Type
Legal address
Permanent
Mailing
Home
(MM-DD-YYYY)
Must be at least 5 years old (Pfizer)
Gender
Male
Female
Unknown
Non-Binary
Race
American Indian OR Alaska Native
Asian
Black or African-American
Native Hawaiian or Other Pacific Islander
White
Other Race
Prefer not to Specify
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Prefer not to Specify
Population
Law Enforcement
Fire/EMS
School Staff
65+ Community
Clergy
Other
-
Yes
No
Do you have medicare?
-
Yes
No
Do you have other insurance?
Insurance Carrier
Aetna
AmeriHealth
Cigna
Horizon BCBS
Humana Military
Medicaid
Other
United HealthCare
Name of Insurance Company
Do you require a handicap ramp for access?
No out of pocket expense for vaccine, insurance information is requested to help offset the cost of providing this service to you as the resident.
COVID-19 Questionnaire
-
Yes
No
Have you had ANY vaccine in the last 60 days?
Please call our office at 609-492-1212
-
Yes
No
Are you currently taking antibiotics or antiviral medications to treat an acute infection?
Current active infection being treated with antibiotics may prevent you from being clinically cleared at the vaccination site for receipt of vaccine on that day.
-
Yes
No
Are you currently in isolation or quarantine due to COVID-19?
-
Yes
No
Do you have a fever or ≥100.4 degrees Fahrenheit?
-
Yes
No
Have you had a severe allergic reaction to any vaccine, injectable medication, or any other cause or do you carry an epi-pen?
-
Yes
No
Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as a treatment for COVID-19 in the past 90 days?
-
Yes
No
Are you immunocompromised?
-
Yes
No
Do you have a bleeding disorder or are you taking a blood thinner?
-
Yes
No
Do you have a history of or a risk for a blood clotting disorder?
-
Yes
No
Pregnant or breastfeeding?
-
Yes
No
Do you have a history of Guillain-Barre syndrome?
-
Yes
No
Have you been previously vaccinated for Covid-19?
Flu Questionnaire
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Yes
No
Are you sick today?
-
Yes
No
Have you had a flu shot in the past?
-
Yes
No
Do you have any allergies to medication/food/vaccine component/latex?
Continue
Schedule
Vaccine Type
Johnson & Johnson
Moderna
Pfizer
Dose
Schedule
02-01-23, Long Beach Island Health Department 2119 long Beach Bouelvard
02-08-23, Long Beach Island Health Department 2119 long Beach Bouelvard
02-15-23, Long Beach Island Health Department 2119 long Beach Bouelvard
02-22-23, Long Beach Island Health Department 2119 long Beach Bouelvard
Select Time
Select Time
Consent
I have read, or have had explained to me, the FDA Emergency Use Authorization Form about the Vaccine. I acknowledge that I have been given the opportunity to review the LBI Health Department Notice of Privacy Practices on this date. I understand that this vaccine may cause symptoms in some people but will not actually cause the Covid Virus. I have had an opportunity to ask questions which were answered to my satisfaction and I have also been given the opportunity to speak with my personal family physician or pediatrician as it related to the EUA Vaccination program. I understand the benefits and risks of Covid vaccine and request that the vaccine be given to me or for whom I am authorized to make this request. I have answered all questions truthfully and accurately. I request that payment of authorized Insurance benefits be made to me or on my behalf to the Long Beach Island Health Department for any services furnished to me by the LBI Health Department. I authorize any holder of medical information about me to release to the insurance carrier of record and its agents any information needed to determine these benefits or the benefits payable for related services.
I authorize in the event of a medical related emergency to begin medical treatment and/or transportation as deemed by the clinical nursing staff.
By typing your name below, you are signing this form electronically. You further agree that your electronic signature is the legal equivalent of your manual signature on this form.
Click Here to Submit
