Consent For Services

Vaccination Event:

Who is receiving the vaccination(Required)

Vaccination Event(Required)

Please complete this first section and submit the form.

Child's Name(Required)

First Last

Child's Date of birth(Required)

Child's School Name(Required)

Child's Grade(Required)

Patient’s Information:

School Name(Required)

Child's Grade(Required)

Patient Name(Required)

First Middle Inital Last Suffix

Date of Birth(Required)

Age(Required)

Sex(Required)

Race(Required)

Address(Required)

City(Required)

State(Required)

Zip(Required)

Contact Information:

Parents/Guardians(Required)

First Name

Middle Name

Last Name

Suffix

Maiden Name of Child’s Mother(Required)

Mobile Phone Number(Required)

Home Phone Number(Required)

Email Address(Required)

Contact Preference(Required)

Required Health Insurance Information:

Select One(Required)

Private Insurance

Medicaid (ex: Healthy Indiana Plan, Hoosier Care Connect, Hoosier Healthwise)

No Insurance: I certify that the patient is not covered by any health insurance.

Patient’s Primary Care Provider(Required)

Insurance Company(Required)

Member ID(Required)

Group #(Required)

Policy Holder

Name

First Middle Last

Date of Birth(Required)

Employer(Required)

Relationship to Patient(Required)

Upload Insurance Card Image (Front)(Required)

Accepted file types: jpg, jpeg, heic, gif, png, Max. file size: 10 MB.

Upload Insurance Card Image (Back)(Required)

Accepted file types: jpg, jpeg, heic, gif, png, Max. file size: 10 MB.

Demographic Information:

Number of people in household(Required)

Current annual household income(Required)

Consent

Communication

It's ok to call me

It's ok to TXT me

Medical

It’s ok to submit my records to CHIRP

All information I have provided on the consent for vaccination is true and correct. I am aware of the HIPAA Notice of Privacy Policy available at supershot.org. I am aware and understand the CDC Vaccine Information Statements for the vaccines the patient will receive today available at https://www.cdc.gov/vaccines/hcp/vis/index.html. I give permission to Super Shot to give the patient the vaccine in my absence, to communicate with other healthcare providers, as needed, and for data entry, billing, and storage according to Indiana Department of Health policies. By signing below I agree to the payment option for today’s services that I have selected. I understand that if I have asked for a claim to be filed to my insurance company, I am responsible for charges not covered by my insurance plan and agree to pay them in full.

Signature(Required)

Date(Required)