MedPro Vaccination Consent MedPro Vaccination Clinic on October 7, 2025 Step 1 of 5 - Event 0% Please fill out all sections of the form completely, including your personal details and insurance information. Don’t forget to sign and date the form at the end before submitting. We look forward to seeing you on October 7th. Should you require any assistance, please don’t hesitate to contact us at Emilie.Singleton@supershot.org Patient’s Information:Patient Name(Required) First Last Date of birth(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sex(Required)Select OneMaleFemaleAddress(Required)City(Required)Zip(Required)Email Address(Required) Mobile Phone Number(Required) Required Health Insurance Information:Select One(Required) Private Insurance (ex: CIGNA, PHP, BCBS, Signature Care) Medicaid (ex: Healthy Indiana Plan, Hoosier Care Connect, Hoosier Healthwise, CareSource) Medicare or Medicare Replacement/Advantage Plan (Humana Gold, UnitedHealth Care, etc.) No Insurance: I certify that named patient is not covered by any health insurance. Insurance Company(Required)Member ID(Required)Group #(Required)Social Security #(Required)Medicare requires SSN for reimbursement purposes. Policy HolderName First Middle Last Date of Birth(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Employer(Required)Relationship to Patient(Required)Select OneSelfSpouseChildOtherGrandparentGrandchildNephew or NieceFoster ChildWardStepson or StepdaughterEmployeeHandicapped DependentSponsored DependentDependent of a Minor DependentSignificant OtherMotherFatherEmancipated MinorLife PartnerUpload 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.Do you have an additional Medicare Card (Red, White, & Blue or Advantage Plan Card?(Required) Yes No Medicare requires us to capture images of both Advantage Plan cards, and traditional Medicare cards cards, if available, for billing purposes. If you have any questions, please call Super Shot at (260)424-7468 and ask for Janet or email Janet.Paunwar@supershot.org. Thank you! 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)Please Select One123456789101112131415More than 15Annual Household Income(Required)Please Select Income RangeBelow $11,800$11,881-$24,300$24,301-$36,450$36,451-$48,600$48,601-$60,750$60,751-$72,901Over $72,901Race(Required)Select OneWhiteAfrican AmericanAsianHispanicAmerican IndianNatl. Hawaiian, Pac IslAlaskan NativeOtherEthnicity(Required)Select OneHispanic/LatinoNot Hispanic/LatinoDecline to AnswerLanguage(Required)Select OneEnglishSpanishBurmeseOtherPrefer not to answerWhat gender do you identify with?(Required)Select OneMaleFemaleNon-BinaryOtherPrefer not to answerSexual Orientation(Required)Select OneStraight/HeterosexualLesbian or GayBisexualOtherPrefer not to answerDo you have a disability?(Required) Yes No Prefer not to answer Answers are for the person getting the vaccine.Do you have allergies to medications, food, a vaccine ingredient, or latex? (if yes, please note)(Required) Yes No List allergies applicable to the previous question. Enter N/A if None(Required) Add RemoveHave you ever had a serious reaction after receiving a vaccine?(Required) Yes No Have you ever been diagnosed with a heart condition (myocarditis or pericarditis) or have you had Multisystem Inflammatory Syndrome (MIS-A or MIS-C) after an infection with the virus that causes COVID-19?(Required) Yes No Are you pregnant?(Required) Yes No Not Applicable Do you have any of the following: (mark all that apply)(Required) Chronic Heart Disease Kidney Disease Liver Disease Complement Component Deficiency Asplenia Take a medication that lowers resistance to infection History of Chickenpox History of Gillian-Barre syndrome Diabetes/Metabolic Disorder Nervous System Disorder Asthma/RAD Blood Disease CSF Leak Cochlear Implant Weakened Immune System, Cancer, Lupus, HIV/AIDS None of the above ConsentI would like Super Shot to provide the following vaccines:(Required) Updated COVID-19 Influenza High Dose Flu (65+) I consent to receiving Flu Vaccination services from Super Shot.(Required) Yes No Communication It's ok to call me It's ok to TXT me 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 all vaccinations indicated and selected above, 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.Consent for Vaccine Services(Required) I agreeAll information I have provided on the consent for vaccination is true and correct. I am aware the HIPAA Notice of Privacy Policy is available at supershot.org. I am aware and understand that the CDC Vaccine Information Statements (VIS) for the vaccines the patient will receive today are available at https://www.cdc.gov/vaccines/hcp/vis/index.html. I give permission to Super Shot to provide all vaccinations indicated and selected above, 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 terms stated above and 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.Date(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Signature(Required)Untitled
