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Vaccine Appointment Intake Form
This form is to be filled with member/client information of those who have asked for assistance to secure a COVID-19 vaccine appointment.  

To be prepared, have the following information available during the call:
- vaccine site descriptions
- transportation services information
- The Madeleine vaccine website open or address available - https://themadeleine.edu/site/vaccine/

Intake operator notes - begin the call with the following information:
- Introduce yourself and the organization you represent.
- Remind the client that they should never give their personal information over the phone to people whom they do not know. In this case, because they are familiar with this organization and they have reached out for assistance, it is ok.
- Remind the client that there is no guarantee that an appointment will be secured for them. Appointments are hard to come by but every effort will be made. Being flexible will help the process.
- A social security number is never needed to book, cancel or change a COVID vaccine appointment.
- The COVID vaccine is free, however insurance information will be collected.
-  Know that we are here to help answer questions and to direct you to useful resources at any time during your vaccination process
- OUR ASSISTANCE CANNOT BE CONSTRUED AS PROFESSIONAL ADVICE. PLEASE CONSULT YOUR HEALTH CARE PROVIDER WITH QUESTIONS ABOUT THIS OR ANY VACCINE.  

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First and Last Name *
Age *
Date of Birth *
MM
/
DD
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YYYY
Address (street address, city, state, zip) *
Phone number *
1. Lets confirm you are eligible to receive the vaccine. Read and select criterion below (if more than one applies, just select age): *
Required
2. Who usually books your medical appointments?  If someone else, please have that person contact us OR provide them with the vaccine information webpage at https://www.themadeleine.edu/vaccine/ and the state vaccine page at https://covidvaccine.oregon.gov/.  If they would still like help booking their vaccine appointment, continue on through the intake form. *
3. In which metro area county do you live or work? *
4. Are any of the following true? You are younger than 16 years old; You have recently been diagnosed as COVID-19 positive and are currently in isolation; You have been COVID-19 positive in the past 90 days and were treated with monoclonal antibodies; You have been told to quarantine after having close contact with a person who is COVID-19 positive; You have already received your first dose; You had a non-COVID-19 vaccine in the past 14 days; You had an allergic reaction to polyethylene glycol (PEG) or polysorbate; You are sick or have a fever; You have a bleeding disorder or are on a blood thinner; You are immunocompromised or on medicine that affects your immune system or have a history of Guillain-Barre or Bell’s Palsy; You have a history of using dermal filler; You are pregnant, plan to become pregnant or are you breastfeeding.  (If any are true, seek further guidance from a medical professional before returning to us to help you book an appointment.) *
5. Have you had a severe allergic reaction to an injectable medication or any other vaccine? *
6. If yes to question 5, be advised that Oregon Health Authority recommends you discuss the risks and benefits of a COVID-19 vaccine with your doctor. Would you like to continue to schedule your appointment?
Clear selection
7. Have you ever tested positive for COVID-19? (if yes, you are permitted to proceed so long as you are cleared from isolation) *
8. What is the name of your health insurance provider? What is your insurance ID number?  Both are needed if available, however, insurance is not required to receive the vaccine.  In some cases vaccine providers may charge your insurance company administration fee for giving you the vaccine. For this reason you are asked for your insurance information. You can still get the COVID-19 vaccine if you do not have insurance. *
9. Vaccine appointments are limited. You may need to be flexible to take whatever is available. Can you drive yourself or do you have someone with a flexible schedule who can take you to the vaccination site, knowing it might take up to two hours or more?  If not, do you need a referral to a ride service?  If you are an Oregon Health Plan member there may be additional transportation options for you. *
10. See the "Guide to Local Vaccination Sites".  Discuss client needs and select all that are suitable.   *
Required
Additional notes regarding special arrangements at vaccination site (only complete if necessary)
11. You may need to be patient waiting for an appointment as slots fill quickly.  Are there any dates or times you are unavailable for an appointment in the coming month. (The more flexible you are, the sooner you will get an appointment.)
12. Once we book your appointment, we will contact you with the details, give you information about what to expect at your appointment and give you tips for preparing for your visit.  How would you like to be notified when we have secured an appointment for you?   *
Required
If answered "email" to the question above, what is the best email address to use - either their own or the email address of a family member or friend who can receive notice of the appointment?
Additional notes regarding this client (optional)
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