Home COVID 19 FORMS REGISTER

NEW PATIENT REGISTRATION FORM

PATIENT DEMOGRAPHIC

Patient / Child First Name: Middle Name: Last Name:

Previous Name: Preferred Name:

Age: Date of Birth: Soc.Sec.#: Occupation:

Ethnicity: Language: Race: Marital Status:

Mailing Address:

City: State: Zip Code: Home Phone:

Work Phone: Cell Phone:

Email Address: Driver Licence #:

Previous Primary Care Provider (Name / Address / Phone Number): IF ANY

Referring Doctor (If Any):

What MAIN PHARMACY do you use for medication refills:

Pharmacy Address: Pharmacy Phone & Fax:

ALERT NOTICE: The cost of the Pfizer, Moderna, and Johnson-Johnson COVID-19 Vaccines are free. However, according to the Centers for Medicare & Medicaid Services (CMS), medical offices such as SARIN & TAO FMC INC, are allowed to charge a fee for administering the vaccine. Per CMS guidelines, the following are the ADMINISTERING FEES: : 1. Pfizer & Moderna Vaccine 1st Dose: $16.94/each 2. Pfizer & Moderna Vaccine 2nd Dose: $28.39/each 3. Johnson & Johnson Vaccine: $28.39

These fees will be billed to your insurance(s). However, if no insurance or cash payer, we waived the administration fee(s). Thank you.

PRIMARY INSURANCE INFORMATION: Policy Holder to Insurance: Self / Spouse / Parent / Company
Plan Name: ID Number:

Address: Group Number:

Policy Holder: Relationship to Patient:

Effective Date:

Policy Holder's Social Security Number: Policy Holder's Phone Number:

Policy Holder's Date of Birth: Sex:

SECONDARY INSURANCE INFORMATION: Policy Holder to Insurance: Self / Spouse / Parent / Company
Plan Name: ID Number:

Address: Group Number:

Policy Holder: Relationship to Patient:

Effective Date:

Policy Holder's Social Security Number: Policy Holder's Phone Number:

Policy Holder's Date of Birth: Sex:

TERTIARY INSURANCE INFORMATION: Policy Holder to Insurance: Self / Spouse / Parent / Company
Plan Name: ID Number:

Address: Group Number:

Policy Holder: Relationship to Patient:

Effective Date:

Policy Holder's Social Security Number: Policy Holder's Phone Number:

Policy Holder's Date of Birth: Sex:

Financial Responsibility
Financial Responsibility: (Who is Responsible for this Account) Relationship:

Phone Number: Email Address:

I UNDERSTAND THAT MY SIGNATURE REQUEST THAT PAYMENT BE MADE AND AUTHORIZES THE RELEASE OF MEDICAL INFORMATION NECESARY TO PROCESS THE CLAIM. I REQUEST PAYMENT OF BENEFITS TO SARIN & TAO FAMILY MEDICAL CLINIC, INC. I ACKNOWLEDGE THAT I AM FINANCIALLY RESPONSIBLE FOR PAYMENT WHETHER OR NOT COVERED BY THE INSURANCE

I state that the information listed above is accurate and complete. I acknowledge that I am resposible for notifying SARIN & TAO FAMILY MEDICAL CLINIC, INC. of any change to any contact number and / or insurance information.

Name: Date:

Signature: Date:

Relationship To Patient:

* PLEASE SEND INSURANCE CARD AND ID TO THIS EMAIL: Email: admin@stfmc-inc.com

PATIENT CONSENT FORM (COVID-19 VACCINE)
Patient Name: Date of Birth:

Patient Address: Phone #:

* The next 6 fields for Medical Personal .

Date of Vaccination:

Type of Vaccination Given: STATUS:

Lot #: NDC #: EXP DATE: LOCATION:

Dr. Vincent V. Soun MD has given me all the information regarding the COVID-19 VACCINE. He discussed with me all the risks and benefits of the above procedures with my full understanding. All of my questions were answered.

I agree with all the information provided to me by Dr. Soun. I fully consent to receiving the first dose of COVID-19 VACCINE without any restrictions

* If Spanish speaking, my medical translator is provided by:

Patient Signature: Date:

Legal Guardian Name & Signature : Date

Medical Assistant Signature :

Date
Pre-Vaccination Checklist for COVID-19 Vaccines
For vaccine recipients:

The Following questions will help us determine if there is any reason you should not get the COVID-19 vaccine today, If you answer "yes" to any question, It does not necessarily mean you should not be vaccinated. It just means additional questions may be asked. If a question is not clear, please ask you healthcare provider to explain it.

Patient Name: Age:

1.- Are you feeling sick today?

2.- Have you ever receive a dose of COVID-19 vaccine:

      2a.- If yes, which vaccine product?

3.- Have you ever had a severe allergic reaction (e.g. anaphylaxis) to something ? For example, a reaction for which you were treated with epinephrine or EpiPen, or for which you had to go to the hospital ?:

3a.- Was the severe allergic reaction after receiving a COVID-19 vaccine ?

3b.- Was the severe allergic reaction after receiving another vaccine or another injectable medication ?

4.- Have you receive passive antibody therapy (monocional antibodies or convalescent serum) as treatment for COVID-19 ?

4a.- If yes, when antibody received ?       4b.- If yes, where antibody received ?

5.- Have you received another vaccine in the last 14 days ?

6.- Have you had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19 ?

6a.- If yes, When was positive ?       6b.- If yes, where was positive ?

6c.- If yes, what type of test ?

7.- Do you have a weakened immune system caused by something such as HIV Infection or cancer or do you take Immunosuppressive drugs or therapies ?

7a.- If yes, What type of medication or therapy did you take ?

8.- Do you have bleeding disorder or are you taking a blood thinner ?

8a.- If yes, What type of medication ?

9.- Are you pregnant or breasfeeding ?

10.- Any recent surgeries ?

10a.- If yes, What type of surgeries ? 10b.- If yes, When was the surgeries ?

10c.- If yes, where was the surgeries ?

11.- Do you have Dermal Fillers ?

11a.- If yes, What type of them ? 11b.- If yes, When was the last procedure ?