Minden Medical Center – #1 Medical Plaza

First Name (as it appears on your state issued driver's license) *

Last Name (as it appears on your state issued driver's license) *

Please list any previous last names you have used: *

Enter “NONE” if not applicable.

Date of Birth *

PLEASE NOTE: YOU MUST BE AGE 12 OR OLDER ON THE DATE OF VACCINATION IN ORDER TO RECEIVE THE PFIZER COVID-19 VACCINE.

Gender *

Race *

Ethnicity *

Phone Number *

Example Format: 012-345-6789

Address *

City *

State *

Zipcode *

Social Security Number *

Example Format: 123-45-6789

Primary Insurance Company/Medicare/Medicaid *

Enter “NONE” if not applicable.

Primary - Policy Number/Medicare Number *

Enter “NONE” if not applicable.

Secondary Insurance Company/Medicare/Medicaid *

Enter “NONE” if not applicable.

Secondary - Policy Number/Medicare Number *

Enter "NONE" if not applicable.

SCREENING QUESTIONS

IMPORTANT NOTE: If you answer "Yes" to any of Screening Questions 1-3, you are not currently eligible to receive the COVID-19 vaccine at this time.

1. Have you had any COVID antibody treatments within the last 3 months? *

Yes

NOTE: If "yes" you are NOT eligible to receive the COVID-19 vaccination. You must wait 90 days after the antibody treatment to receive a COVID-19 vaccination.

2. Have you had COVID-19 in the last 21 days? *

Yes

NOTE: If "yes" you are NOT eligible to receive the COVID-19 vaccination at this time. You must be negative for COVID-19 for 21 days.

3. Are you a healthcare worker? *

Yes

4. Are you a Minden Medical Center Employee? *

Yes

SCREENING QUESTIONS CONTINUED:

5. Have you been vaccinated for COVID-19 in the past? *

Yes

5a. Which COVID-19 Vaccination have you received? *

6. Do you have any severe anaphylactic allergies (food, vaccine, medications, insect, etc.)? *

Yes

NOTE: Everyone will be under observation for 15 minutes after receiving the vaccine or 30 minutes if you have ever had an allergic reaction to anything.

7. I reviewed the EUA documentation regarding this vaccination. *

Yes

The Emergency Use Authorization documentation is linked above and can also be found here: https://www.modernatx.com/covid19vaccine-eua/eua-fact-sheet-recipients.pdf

8. I agree to have the second dose in 21 days. *

Yes

COVID-19 Vaccination Appointment:

Select an Appointment Date & Time *

Registration is currently open for COVID-19 vaccination appointments on September 25, 2021. If you are coming for your second dose on October 16, 2021, you do not need to re-register.

I meet the current COVID-19 vaccination criteria and I am willing to receive the COVID-19 vaccine. *

Yes, I confirm that I meet the criteria (age 12+) and that I am willing to receive the vaccine.

reCAPTCHA

MMC COVID-19 Vaccination Clinic Registration

Registration for the COVID-19 Vaccine Clinic at St. Rest Baptist Church – 611 E Union St, Minden, LA 71055 is now OPEN.

If you are scheduled to receive the first dose of the COVID-19 vaccine on Saturday, September 25, between 9am – 11am you will return to St. Rest Baptist Church at 611 East Union Street on Saturday, October 16, between 9am – 11am.

SCREENING QUESTIONS

SCREENING QUESTIONS CONTINUED:

COVID-19 Vaccination Appointment: