Relief App

Adult Participant

Participant consents to having their information shared with appropriate state healthcare agencies.

Anticipated vaccinations

Moderna Covid 6+ years booster bivalent 229
Pfizer Covid 5 years - 11 years booster bivalent 301
Pfizer Covid 12+ years booster bivalent 300
Sanofi Pasteur Fluzone, influenza, injectable, quadrivalent, contains preservative, multi-dose vial primary 158
Seqirus Flucelvax Quadrivalent, Influenza injectable, MDCK, PRESERVATIVE FREE primary multivalent 171

Location

Government Issued ID

Covid Vaccination Card

Participant First Name

Participant Middle Name

Participant Last Name

Participant Email (required if participant is an adult)

Participant Phone (required if participant is an adult)

Participant Social Security Number (SSN optional)

Participant Date of Birth (mm/dd/yyyy)

Participant Sex

Participant Race

Participant Ethnicity

Select if you do not have health insurance.

Insurance

Health Insurance

Health Insurance (Required only if Other was selected above)

Health Insurance Member ID

Health Insurance Group ID

Health Insurance Plan ID (Optional)

Relationship to Person Insured (self, spouse, child, etc.)

Insurance Card Front

Insurance Card Back

Address

Address1

Address2

City

State

Zip Code