Boys and Girls Club of Santa Monica – Vaccine Form

KEEPING OUR MEMBERS SAFE AND OUR FACILITIES OPEN

Boys and Girls Club of Santa Monica IS PARTNERING WITH INSPIRE DIAGNOSTICS TO OFFER CONVENIENT COVID-19 VACCINE CLINICS WITH NO OUT-OF-POCKET COST*

KEEPING OUR MEMBERS SAFE AND OUR FACILITIES OPEN

Boys and Girls Club of Santa Monica IS PARTNERING WITH INSPIRE DIAGNOSTICS TO OFFER CONVENIENT COVID-19 VACCINE WORKPLACE CLINICS WITH NO OUT-OF-POCKET COST*

Boys and Girls Club Employee and Members: Pre-Register for Covid Testing at the Event

Guests and all other individuals: Pre-Register for Covid Testing at the event

Register for vaccination

COVID-19 Testing and Vaccination Event

December 11, 2021

Boys and Girls Club of Santa Monica
1220 Lincoln Blvd
Santa Monica, CA 90401

Vaccine Registration Form

Step 1 of 4

Vaccination General Information

Inspire Diagnostics is pleased to be offering COVID vaccine mobile services to area facilities. The primary focus of this mobile facility-based event is to provide personable and convenient vaccination access for valued team members and their household.

Please complete this form for each eligible individual that would like to be vaccinated at the workplace hosted event. A consenting parent/guardian must consent and be present at the time of vaccination of a minor( younger than 18 years), unless individual is an emancipated minor.

Inspire may offer Pfizer, Moderna, and Johnson & Johnson vaccines (primary 2-part series and booster dose). Vaccine availability is based on the Department of Public Health allocations.

Patient Personal Information

Name*

First Last

Please select the patient's age range*

People younger than 18 years must have parental or guardian consent, unless patient is an emancipated minor.

Date of Birth*

Demographic

Sex

Race

Ethnicity

Mailing Address

Address*

Street Address Address Line 2 City State ZIP Code

Contact Information

Email*

Enter Email Confirm Email

Mobile Number*

Vaccination Background

Which Vaccine Service would this Individual Receive at the Upcoming Workplace Vaccine Event? (choose only one)

Primary Series

Booster

Consent

Consent*

I certify that the below is true to the best of my knowledge

I certify that I am: (a) the patient and at least 18 years of age; (b) the legal guardian of the patient and confirm that the patient is at least 5 years of age; or (c) legally authorized to consent for vaccination for the patient named above. Further, I hereby give my consent to Inspire Diagnostics or its agents to administer the COVID-19 vaccine.

I understand that this product has not been approved or licensed by FDA, but has been authorized for emergency use by FDA, under an EUA to prevent Coronavirus Disease 2019 (COVID-19) for use in individuals either 5 years of age or older or 18 years of age and older; and the emergency use of this product is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of the medical product under Section 564(b)(1) of the FD&C Act unless the declaration is terminated or authorization revoked sooner.

I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccine(s). I understand the risks and benefits associated with the above vaccine and have received, read and/or had explained to me the Emergency Use Authorization Fact Sheet on the COVID-19 vaccine I have elected to receive. I also acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction.

I acknowledge that I have been advised to remain near the vaccination location for approximately 15 minutes (or more in specific cases) after administration for observation. If I experience a severe reaction, I will call 9-1-1 or go to the nearest hospital.

On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless Inspire Diagnostics and its staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the vaccine listed above.

I acknowledge that: (a) I understand the purposes/benefits of the state’s immunization registry and (b) Inspire Diagnostics will include my personal immunization information in the appropriate state registry and my personal immunization information will be shared with the Centers for Disease Control (CDC) or other federal agencies.

I further authorize Inspire Diagnostics or its agents to submit a claim to my insurance provider or Medicare Part B without supplemental coverage payment for me for the above requested items and services. I assign and request payment of authorized benefits be made on my behalf to Inspire Diagnostics or its agents with respect to the above requested items and services. I understand that any payment for which I am financially responsible is due at the time of service or if Inspire Diagnostics invoices me after the time of service, upon receipt of such invoice.

On behalf of the patient, the patient’s heirs and personal representatives, I hereby waive any claim I may have against the District, the County, the healthcare professional, and each of their respective governing board, officers, agents, employees, volunteers, and representatives (“Released Parties”) from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the vaccine(s).

Our goal is to help all members return to their lives safely, with peace of mind.

*Inspire Diagnostics will bill your health plan, the government, a government health plan or the uninsured fund for the vaccine. There will be no patient out-of-pocket cost.

QUESTIONS? CONTACT US

Vaccination General Information

Patient Personal Information

Demographic

Mailing Address

Contact Information

Vaccination Background

Insurance Information

Private Insurance

Medicare

No Insurance

Consent