COVID-19 Vaccine Request Form
Thank you for your interest in receiving the COVID-19 Vaccine. BETHLEHEM FAMILY HEALTHCARE has been approved as a mass vaccination site. You do not need to be an established patient with BETHLEHEM FAMILY HEALTHCARE to schedule your vaccination.
Note that the Pfizer vaccine is indicated for those 12 years old and above, while the Moderna vaccine is indicated for those 18 years old and above.
Please complete this Request Form AND the Pre-Registration Form. Your personal information will be kept confidential per HIPAA policies. We will only schedule if BOTH FORMS ARE COMPLETED. We will notify you of your scheduled vaccination date and time via EMAIL. This email message will serve as your appointment CONFIRMATION and no phone calls will be made to you anymore. This is to redirect and unload the very high phone call volume our clinic has been receiving.
Other than sharing your information through the Georgia Vaccine Registry and the Georgia Department of Public Health, your information will not be sold or shared. It will only be used for coordination of your COVID-19 vaccination.
Please bring photocopies of your health insurance card, (front and back, including Medicare if applicable) AND valid photo ID (photocopy), to expedite the process. The state GRITS vaccine registry may require your SSN on the date of appointment.
See FAQs section down below for more information.
Sign in to Google
to save your progress.
Patient First Name
Patient Last Name
Name of Parent/Guardian (if less than 18yo)
Date Of Birth
Declined to Specify
Do you have a Primary Care Physician/Provider?
I am . . . (please choose all that apply)
18 years old and above (Moderna Vaccine)
12 years old and above (Pfizer Vaccine)
Primary Health Insurance Name (Medicare, if applicable)
Primary Health Insurance Group#
Primary Health Insurance Policy#
Secondary Health Insurance, if any:
Secondary Health Insurance Group #
Secondary Health insurance Policy #
May we communicate your appointment by email?
"I, the undersigned (patient or legal guardian if less than 18yo), consent to the administration of COVID vaccine on the date of my appointment. I have provided Bethlehem Family Healthcare with the information needed to the best of my ability. I release Bethlehem Family Healthcare and its volunteers and employees from any liability relating to COVID Vaccine administration. I have read, fully understood and agreed to the above important information." [Patient (Parent/Guardian if less than 18yo) name here as signature]
FREQUENTLY ASKED QUESTIONS
Please read and understand the information given below. As you can imagine, our office is overwhelmed with phone calls and inquiries about the virus and the vaccine, so please read all the information here before attempting to call our office.
HOW LONG BEFORE MY APPOINTMENT CAN BE SCHEDULED?
We can schedule your appointment as soon as possible.
WHAT SHOULD I BRING TO MY APPOINTMENT?
PHOTO ID - Please bring your valid photo ID such as driver's license, passport or state identification card.
INSURANCE CARD(S) - Please bring your insurance card(s) including your Medicare card.
MASK - Please make sure you bring a mask and wear it at all times while on the property.
WHERE WILL THE VACCINES BE GIVEN?
When we notify you of your appointment day and time, we will let you know if you need to come to our office (323 Resource Pkwy, Winder, GA 30680) or to an alternative location in the community during a mass vaccination clinic that we would organize.
HOW LONG WILL THE PROCESS TAKE?
Appointments will last approximately 30 minutes, which will INCLUDE an observation period of 15 minutes to make sure you do not have any adverse reactions to the vaccine. If you have a history of severe allergies, you may be asked to stay for a longer time after getting your shot.
DO I HAVE TO HAVE INSURANCE TO GET THE VACCINE?
Insurance is not required. If you do have insurance, however, please bring your insurance card(s) with you, including your red, white and blue Medicare card.
Only an Administration Fee will be charged to your insurance to pay for the resources, supplies and staff. If your insurance does not cover the fee, we will waive the it at no cost to you. The vaccine is FREE.
DO I HAVE TO HAVE A SCHEDULED APPOINTMENT?
Yes. Appointments are required due to COVID precautions.
WHAT ABOUT THE FOLLOW UP VACCINE OR SECOND DOSE?
If this is a first dose appointment, we will schedule the follow-up second dose appointment. Second dose appointments will be made during your initial appointment. Pfizer vaccines are administered 21 days apart and Moderna vaccines 28 days apart.
WHERE CAN I GET INFORMATION REGARDING COVID, THE COVID VACCINE, and ELIGIBILITY?
Reliable information can be found on the CDC website, Georgia DPH website, Pfizer website, and Moderna website.
Please the click SUBMIT button below then proceed to STEP 2 to complete your registration.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service