COVID-19 Vaccination Request

Please do not submit duplicate registration requests as this may delay processing of your request.
Personal Information
Name*
Legal First Name Legal Last Name
Date of Birth
Date Format: MM slash DD slash YYYY
Date of Birth*
SSN
Gender*
Weight
Please enter a number from 1 to 999.
Ethnicity*
Race*
Are you a University of Kentucky HMO/PPO/EPO/RHP/SAVER member:*
- Yes
- No

Contact Information
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Enter Email Confirm Email

If you do not have an email address please enter: noemail@noemail.com

Occupation Information
Is the person wanting to be vaccinated a University of Kentucky student or employee?*
- Yes
- No
I am a...*
- UK HealthCare Employee
- University of Kentucky Employee
- University of Kentucky Student
UK ID*

Medical Information
Will this be your first, second, third, fourth dose?*
Which vaccine did you receive?*
Date of first vaccine dose*
Date of second vaccine dose*
Date of third vaccine dose*
During the past 90 days, have you received passive antibody therapy for COVID-19?*
- Yes
- No

All the information provided is correct to the best of my knowledge. I authorize the following: the release of any medical or other information with respect to this vaccine to my healthcare providers, Medicare, Medicaid, or other third-party payer, as needed, as well as to the FDA. I acknowledge that my vaccination record may be shared with federal or state agencies for registry reporting; and that the provider or pharmacist recommends that I remain in the waiting area for 20 minutes after receiving the vaccine to be observed for a reaction. If I receive curbside vaccination, I understand it is still recommended to remain nearby for 20 minutes and to quickly notify the UKHealthCare staff of any reactions. I have had the opportunity to ask questions that were answered to my satisfaction and understand the benefits and risks of the vaccine(s). I give consent for the administration of the COVID-19 vaccine(s). I have read or have had read to me the Vaccination Information Sheet (VIS) regarding the vaccine(s), and I hereby acknowledge a scheduled receipt of the COVID-19 vaccine.
Please enter your initials:*
Comments
This field is for validation purposes and should be left unchanged.

Personal Information