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Vaccine Card
Registration

Derek's Bar Mitzvah
October 9, 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.

PLEASE DO NOT RE-SUBMIT THIS FORM. If you are having trouble, please contact Erica.

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Guest Information

Personal Information:

First Name of Guest:

Last Name of Guest:

Date of Birth of Guest:

Vaccine Card Upload

Vaccine Card (front):

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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.

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