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 FormNightingale 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. Curent Phase of Rollout *IMPORTANT*Please see the provided link to ensure that you are in the current phase for the vaccine administration. We will only vaccinate those that fit the requirements for the current phase of the vaccine rollout. https://dph.georgia.gov/covid-vaccineVaccine 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.Name* First Last Date of Birth* Date Format: MM slash DD slash YYYY Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email Office LocationPlease select which office is closest to your residenceOffice Location*AlbanyAthensAugustaDouglasBrunswickColumbusMaconMariettaSandersvilleSavannahStatesboroInsurance File SubmissionPlease submit a copy of your primary and secondary insurance cards.FileAccepted file types: jpg, png, pdf.