Minden Medical Center – #1 Medical Plaza

First Name *

Last Name *

Please list any previous last names you have used: *

Enter “NONE” if not applicable.

Date of Birth *

PLEASE NOTE: YOU MUST BE AGE 18 OR OLDER ON THE DATE OF VACCINATION IN ORDER TO RECEIVE THE MODERNA 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 any vaccines in the past 14 days? *

Yes

NOTE: If "yes" you are NOT eligible to receive a COVID-19 vaccination. You must wait 14 days after the most recent vaccine was received.

3. 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.

SCREENING QUESTIONS CONTINUED:

4. 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.

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

Yes

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

6. I agree to have the second dose in 28 days. *

Yes

COVID-19 Vaccination Appointment:

Select an Appointment Date & Time *

Registration is currently open for COVID-19 vaccination appointments on April 15. If you are coming for your second dose on this date, 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 18+) and that I am willing to receive the vaccine.

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MMC COVID-19 Vaccination Clinic Registration

Upcoming COVID-19 Vaccine Clinic Dates:

DATE: Thursday, April 15 TIME: 8 a.m. – 12 p.m. LOCATION: Minden Medical Center (1 Medical Plaza Pl., Minden, LA 71055)

IMPORTANT NOTE: You must be age 18 or older on the date of the vaccination clinic in order to receive the Moderna COVID-19 vaccine.

To register for your COVID-19 vaccine, fill out the form below completely and accurately. PRE-REGISTRATION IS REQUIRED. To register by phone, please call 318-382-8282. We are unable to schedule appointments by text, social media messages, or email.

SCREENING QUESTIONS

SCREENING QUESTIONS CONTINUED:

COVID-19 Vaccination Appointment:

DATE: Thursday, April 15
TIME: 8 a.m. – 12 p.m.
LOCATION: Minden Medical Center (1 Medical Plaza Pl., Minden, LA 71055)