COVID-19 VACCINATION REGISTRATION FORM

Please fill out the COVID-19 consent form and we will contact you when we are able to have you come to one of our locations for a COVID-19 vaccination.
  • COVID-19 Vaccine Registration Form

    Nightingale is working diligently with the CDC and the Georgia Department of Health to procure and administer the vaccine to the population in accordance to safety guidelines. We will reach out to you to schedule your COVID-19 vaccination following phase 1,2, or 3 rollout.
  • Vaccine Location For First and Second Dose of COVID-19 Vaccine *IMPORTANT*

    Please note that if you have received your first dose of the COVID-19 vaccine at a licensed provider ie. CVS, Kroger, the local hospital, or Nightingale Infusion. Then you must also receive your second dose from the same provider. We will not allow second doses to those who have not had their first dose with us.
  • Date Format: MM slash DD slash YYYY
  • Office Location

    Please select which office is closest to your residence
  • Insurance File Submission

    Please submit a copy of your primary and secondary insurance cards.
  • Accepted file types: jpg, png, pdf.