WELCOME TO EVERPOINT

Vaccine Card
Registration

Peek - Rossi Wedding
September 11, 2021

Please enter all information accurately as possible. If you have any trouble, kindly feel free to contact Erica at etripodi@everpointhealth.com or 203-517-7687.

This form is secure and HIPAA-compliant .

Guest Information

Personal Information:

First Name of Guest:

Last Name of Guest:

Date of Birth of Guest:

Vaccine Card Upload

Vaccine Card (front):

Upload File

Patient Consent

By checking the general consent box below, I certify that I am either (1) at least 18 years of age or (2) I am legally recognized as an ‘emancipated minor’ by the state in which I reside or (3) I am the parent or legal guardian of the minor on behalf of whom the vaccine card is provided.

I hereby authorize Everpoint Medical, PLLC / Everpoint Health, LLC to disclose this information to my event host. The purpose of this disclosure is to provide information to the above listed individual/entity for infectious disease management. I understand that I may refuse to sign this authorization.

I accept the above conditions.

Thanks for submitting!