COVID-19 Vaccine Registration
The Bear River Health Department is currently providing COVID vaccinations. Our allotment of vaccine is only for those who live or work in Box Elder, Cache, or Rich counties. If you do not meet this criteria, please visit brhd.org regularly for updates on when the vaccine will be available to you. Please be prepared to show proof of age or employment when you arrive at the vaccination clinic.
NOTICE for those that do not meet current target population criteria for vaccine administration.
If you do not meet this criteria, please visit brhd.org regularly for updates on when the vaccine will be available to you.
Have you tested positive for COVID-19 in the last 90 days?
*
Yes
No
NOTICE for those testing positive for COVID-19 in the last 90 days
It is not recommended for those who have had COVID-19 in the last 90 days to receive the vaccine. Please check back in with the Bear River Health Department at a later date to receive yours.
Have you received the first dose of the COVID-19 vaccination?
*
Yes
No
NOTICE for those who have received a 1st Dose of COVID-19 vaccine
This form is for those persons needing the 1st Dose of the Moderna COVID-19 vaccination. If you need to schedule an appointment for 2nd Dose, please visit brhd.org for information about 2nd Dose clinics.
Name
*
First Name
Last Name
Patient Birth Date
*
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Month
-
Day
Year
Date
Gender
*
M
F
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Age
*
Please Select
18
19
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Patient Race
*
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Hispanic/Latino
Other
Clinic Location
*
Bear River Health Department, 817 W 950 S, Brigham City, UT
Appointment
*
Has the patient had a severe allergic reaction to any vaccination?
*
Yes
No
Does the patient have any allergies?
*
Yes
No
Has the patient had another vaccine in the last 14 days?
*
Yes
No
Do you understand the recommendation to wait 15 minutes for any adverse reactions?
*
Yes
No
By clicking this box below you acknowledge the above statements are true. This acknowledgment serves as your digital signature.
*
Yes
Back
Next
Insurance Information
If you will be using insurance for your immunizations please complete this section. Be sure to bring your card or a copy of your card with you.
Are you insured?
*
Yes
No
Insurance Company
Policy Subscriber ID Number
If possible, please attach a copy or a photo of your insurance card. Include front and back. Add file
Browse Files
Drag and drop files here
Choose a file
Cancel
of
If uninsured, what is your driver's license State and number (example UT 123456)?
If the patient is the policyholder you may skip the rest of this section. If the patient IS NOT the policyholder be sure to complete all remaining questions in this section.
Policy Holder's Name?
Policy Holder's Date of Birth
-
Month
-
Day
Year
Date
Policy Holder's Relation to Patient
Policy Holder's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Policy Holder's Phone Number
Please enter a valid phone number.
By clicking this box below you acknowledge the above statements are true. This acknowledgment serves as your digital signature.
*
Yes
Back
Next
HIPAA
I acknowledge receipt of a copy of the Bear River Health Department (Health Department) Notice of Privacy Practices-For Protected Health Information (Notice), which I have or will carefully review, and acknowledge my rights for a more complete description and understanding of potential uses, disclosures of and/or requests for such protected health information by the Health Department. I acknowledge the Health Department reserves for itself the right to change the terms of its Notice at any time, and if the Health Department does not change the terms of its Notice, I acknowledge the right to obtain a copy of the current revised Notice at any Health Department office.
By clicking this box below you acknowledge the above statement is true. This acknowledgment serves as your digital signature.
*
Yes
COVID-19 Vaccine Information Sheet (Moderna pages 1-5; Pfizer pages 6-11)
Acknowledge Vaccine Information Sheet?
*
Yes
Consent for Services
I have been provided with information about the immunization I will be receiving. I understand I will have a chance to ask questions about the vaccine at the clinic. I believe I understand the benefits and risks of the vaccine.
By clicking this box below you acknowledge the above statements are true. This acknowledgment serves as your digital signature.
*
Yes
v-safe
Hidden Fields (for back-end use)
Interface ID
Facility ID
Administering Facility ID
Vaccination date
Vaccine CVX Code (Moderna: 207; Pfizer: 208)
Route Code
Immunization Site
Date file uploaded
Vaccine Manufacturer (Moderna MOD, Pfizer PFI)
Financial Class
Submit
Should be Empty: