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 Name Last 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 *

RCFE SNF CCRC Other

Facility Physical Address (address where patient is located) *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Facility Contact Number *

Please enter a valid phone number.

Point of Contact at Facility *

First Name Last 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? *

Yes No

Resident's Name *

First Name Last Name

Resident's Date of Birth *

Month Day Year

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

First dose Second dose

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

Pfizer Moderna

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

Month Day Year

Is this resident a Kaiser patient? *

Yes, Kaiser No, not Kaiser

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

I have more resident referrals to make *

Yes No, that is all of the resident referrals I am making today

Second Resident's Name *

First Name Last Name

Resident's Date of Birth *

Month Day Year

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

First dose Second dose

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

Pfizer Moderna

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

Month Day Year

Is this resident a Kaiser patient? *

Yes, Kaiser No, not Kaiser

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

I have more resident referrals to make *

Yes No, that is all of the resident referrals I am making today

Third Resident's Name *

First Name Last Name

Resident's Date of Birth *

Month Day Year

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

First dose Second dose

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

Pfizer Moderna

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

Month Day Year

Is this resident a Kaiser patient? *

Yes, Kaiser No, not Kaiser

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

I have more resident referrals to make *

Yes No, that is all of the resident referrals I am making today

Fourth Resident's Name *

First Name Last Name

Resident's Date of Birth *

Month Day Year

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

First dose Second dose

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

Pfizer Moderna

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

Month Day Year

Is this resident a Kaiser patient? *

Yes, Kaiser No, not Kaiser

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

I have more resident referrals to make *

Yes No, that is all of the resident referrals I am making today

Fifth Resident's Name *

First Name Last Name

Resident's Date of Birth *

Month Day Year

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

First dose Second dose

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

Pfizer Moderna

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

Month Day Year

Is this resident a Kaiser patient? *

Yes, Kaiser No, 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? *

Yes No

Name of first staff person being referred *

First Name Last Name

Staff Date of Birth *

Month Day Year

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

First dose Second dose

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

Pfizer Moderna

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

Month Day Year

Is this staff person a Kaiser patient? *

Yes, Kaiser No, not Kaiser

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

I have more staff referrals to make *

Yes No, that is all of the resident referrals I am making today

Name of second staff person being referred *

First Name Last Name

Staff Date of Birth *

Month Day Year

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

First dose Second dose

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

Pfizer Moderna

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

Month Day Year

Is this staff person a Kaiser patient? *

Yes, Kaiser No, not Kaiser

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

I have more staff referrals to make *

Yes No, that is all of the resident referrals I am making today

Name of third staff person being referred *

First Name Last Name

Staff Date of Birth *

Month Day Year

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

First dose Second dose

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

Pfizer Moderna

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

Month Day Year

Is this staff person a Kaiser patient? *

Yes, Kaiser No, not Kaiser

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

I have more staff referrals to make *

Yes No, that is all of the resident referrals I am making today

Name of fourth staff person being referred *

First Name Last Name

Staff Date of Birth *

Month Day Year

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

First dose Second dose

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

Pfizer Moderna

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

Month Day Year

Is this staff person a Kaiser patient?

Yes, Kaiser No, not Kaiser

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

I have more staff referrals to make *

Yes No, that is all of the resident referrals I am making today

Name of fifth staff person being referred *

First Name Last Name

Staff Date of Birth *

Month Day Year

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

First dose Second dose

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

Pfizer Moderna

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

Month Day Year

Is this staff person a Kaiser patient? *

Yes, Kaiser No, not Kaiser

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