Marin County Residential Care Facilities Vaccination Request Form

If you are interested in the Marin County Public Health Mobile Vaccination team visiting your home or place of business (not a healthcare facility), please click here.

Your Name*

First NameLast Name

Your Phone Number*

Please enter a valid phone number.

Your Email Address*

example@example.com

Facility Name*

Name of facility (if not shown above)*

Type of Facility*

RCFESNFCCRCOther

Facility Physical Address (address where patient is located)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Facility Contact Number*

Please enter a valid phone number.

Point of Contact at Facility*

First NameLast Name

Point of Contact Phone Number*

Please enter a valid phone number.

Information about resident(s) being referred for COVID-19 vaccination

Do you have a resident referral to make?*

YesNo

Resident's Name*

First NameLast Name

Resident's Date of Birth*

MonthDayYear

Is this the resident's first or second dose?*

First doseSecond dose

What is your preference for manufacturer?*

PfizerModernaJ&JNo Preference

If you are referring the resident for a second dose, what is the name of the manufacturer of the first dose?*

PfizerModerna

If you are referring the resident for a second dose, what was the date of their first dose? *

MonthDayYear

Is this resident a Kaiser patient?*

Yes, KaiserNo, not Kaiser

Please add any notes about the request for resident #1 here

I have more resident referrals to make*

YesNo, that is all of the resident referrals I am making today

Second Resident's Name*

First NameLast Name

Resident's Date of Birth*

MonthDayYear

Is this the resident's first or second dose?*

First doseSecond dose

What is your preference for manufacturer?*

PfizerModernaJ&JNo Preference

If you are referring the resident for a second dose, what is the name of the manufacturer of the first dose?*

PfizerModerna

If you are referring the resident for a second dose, what was the date of their first dose? *

MonthDayYear

Is this resident a Kaiser patient?*

Yes, KaiserNo, not Kaiser

Please add any notes about the request for resident #2 here

I have more resident referrals to make*

YesNo, that is all of the resident referrals I am making today

Third Resident's Name*

First NameLast Name

Resident's Date of Birth*

MonthDayYear

Is this the resident's first or second dose?*

First doseSecond dose

What is your preference for manufacturer?*

PfizerModernaJ&JNo Preference

If you are referring the resident for a second dose, what is the name of the manufacturer of the first dose?*

PfizerModerna

If you are referring the resident for a second dose, what was the date of their first dose? *

MonthDayYear

Is this resident a Kaiser patient?*

Yes, KaiserNo, not Kaiser

Please add any notes about the request for resident #3 here

I have more resident referrals to make*

YesNo, that is all of the resident referrals I am making today

Fourth Resident's Name*

First NameLast Name

Resident's Date of Birth*

MonthDayYear

Is this the resident's first or second dose?*

First doseSecond dose

What is your preference for manufacturer?*

PfizerModernaJ&JNo Preference

If you are referring the resident for a second dose, what is the name of the manufacturer of the first dose?*

PfizerModerna

If you are referring the resident for a second dose, what was the date of their first dose? *

MonthDayYear

Is this resident a Kaiser patient?*

Yes, KaiserNo, not Kaiser

Please add any notes about the request for resident #4 here

I have more resident referrals to make*

YesNo, that is all of the resident referrals I am making today

Fifth Resident's Name*

First NameLast Name

Resident's Date of Birth*

MonthDayYear

Is this the resident's first or second dose?*

First doseSecond dose

What is your preference for manufacturer?*

PfizerModernaJ&JNo Preference

If you are referring the resident for a second dose, what is the name of the manufacturer of the first dose?*

PfizerModerna

If you are referring the resident for a second dose, what was the date of their first dose? *

MonthDayYear

Is this resident a Kaiser patient?*

Yes, KaiserNo, not Kaiser

Please add any notes about the request for resident #5 here

Information about staff being referred for COVID-19 vaccination

Do you have a staff referral to make?*

YesNo

Name of first staff person being referred*

First NameLast Name

Staff Date of Birth*

MonthDayYear

Is this the staff person's first or second dose?*

First doseSecond dose

Does the staff person have a preference for manufacturer?*

PfizerModernaJ&JNo Preference

If you are referring the staff person for a second dose, what is the name of the manufacturer of the first dose?*

PfizerModerna

If you are referring the staff for a second dose, what was the date of their first dose? *

MonthDayYear

Is this staff person a Kaiser patient?*

Yes, KaiserNo, not Kaiser

Please add any notes about the request for staff person #1 here

I have more staff referrals to make*

YesNo, that is all of the resident referrals I am making today

Name of second staff person being referred*

First NameLast Name

Staff Date of Birth*

MonthDayYear

Is this the staff person's first or second dose?*

First doseSecond dose

Does the staff person have a preference for manufacturer?*

PfizerModernaJ&JNo Preference

If you are referring the staff person for a second dose, what is the name of the manufacturer of the first dose?*

PfizerModerna

If you are referring the staff for a second dose, what was the date of their first dose? *

MonthDayYear

Is this staff person a Kaiser patient?*

Yes, KaiserNo, not Kaiser

Please add any notes about the request for staff person #2 here

I have more staff referrals to make*

YesNo, that is all of the resident referrals I am making today

Name of third staff person being referred*

First NameLast Name

Staff Date of Birth*

MonthDayYear

Is this the staff person's first or second dose?*

First doseSecond dose

Does the staff person have a preference for manufacturer?*

PfizerModernaJ&JNo Preference

If you are referring the staff person for a second dose, what is the name of the manufacturer of the first dose?*

PfizerModerna

If you are referring the staff for a second dose, what was the date of their first dose? *

MonthDayYear

Is this staff person a Kaiser patient?*

Yes, KaiserNo, not Kaiser

Please add any notes about the request for staff person #3 here

I have more staff referrals to make*

YesNo, that is all of the resident referrals I am making today

Name of fourth staff person being referred*

First NameLast Name

Staff Date of Birth*

MonthDayYear

Is this the staff person's first or second dose?*

First doseSecond dose

Does the staff person have a preference for manufacturer?*

PfizerModernaJ&JNo Preference

If you are referring the staff person for a second dose, what is the name of the manufacturer of the first dose?*

PfizerModerna

If you are referring the staff for a second dose, what was the date of their first dose? *

MonthDayYear

Is this staff person a Kaiser patient?

Yes, KaiserNo, not Kaiser

Please add any notes about the request for staff person #4 here

I have more staff referrals to make*

YesNo, that is all of the resident referrals I am making today

Name of fifth staff person being referred*

First NameLast Name

Staff Date of Birth*

MonthDayYear

Is this the staff person's first or second dose?*

First doseSecond dose

Does the staff person have a preference for manufacturer?*

PfizerModernaJ&JNo Preference

If you are referring the staff person for a second dose, what is the name of the manufacturer of the first dose?*

PfizerModerna

If you are referring the staff for a second dose, what was the date of their first dose? *

MonthDayYear

Is this staff person a Kaiser patient?*

Yes, KaiserNo, not Kaiser

Please add any notes about the request for staff person #5 here