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 1-2, 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

COVID-19 Vaccination Appointment:

Select an Appointment Date & Time *

Registration is currently open for First Dose, Second Dose, OR Booster COVID-19 vaccination appointments on December 2 & 3, 2021.

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 Minden Medical Center is now OPEN.

THE 12/2/2021 & 12/3/2021 CLINICS ARE FOR INDIVIDUALS WHO ARE RECEIVING THEIR FIRST SHOT, SECOND SHOT OR A BOOSTER SHOT.

SCREENING QUESTIONS

SCREENING QUESTIONS CONTINUED:

COVID-19 Vaccination Appointment: