Patient Information

My First Name
  Middle Initial
My Last Name
DOB
Mobile Number
Email
Password
What sex were you assigned at birth?
How do you identify your gender?
Street Address
Apt/Suite
City
State
County
Zip Code
What race do you identify as?
Do you identify as Hispanic, Latino or Latina?

Health Insurance

COVID-19 vaccinations are free for you !
Insurance is not required, but if you have insurance, the vaccine provider will bill your insurance company for an administration fee. You will not be charged a copayment.
Do you have health insurance?
Type of Insurance
Company Name
Recipient ID Number
Beneficiary ID Number
Plan Name
PCN
BIN
Effective Date of Coverage
Effective Date of Coverage
PCN
BIN
Plan Name
* Member ID Number
Group Number
PCN
BIN
Relationship To Policyholder
Policyholder's First Name
Policyholder's Last Name
Policyholder's Date of Birth
Effective Date of Coverage

Please download VIPHealth to manage your COVID-19 vaccination appointment.

To access VIPHealth app, please scan QR code below, or search "VIPHealth" in App Store/ Google Play.

Download VIPHEALTH