Vaccination Appointment Request Form

1. CONTACT INFORMATION
Name*
Last First Full Middle
Date of Birth*
Gender*
- Male
- Female
Race*
- American Indian or Alaska Native
- Asian
- White
- Black or African American
- Native Hawaiian or Pacific Islander
- Other
- Patient Declined
Ethnicity*
- Hispanic, Latino, or Spanish Origin
- Not Hispanic, Latino, or Spanish Origin
- Patient Declined
Existing Underlying Medical Conditions per Hawaii Department of Health (Check all that apply)*
- Anyone currently on home oxygen
- Anyone currently on dialysis
- Anyone currently receiving chemotherapy or other infusion therapy
- Transplant recipient on immunosuppressant medications or on the transplant waiting list
- None
I am an essential worker
- Yes
Employer Name*
Primary Care Provider
Home/Physical Address*
Street City State Zipcode
Mailing Address
Same as Home/Physical Address

Street/PO Box City State Zipcode
Phone Number*
Email*
Insurance Name
Policy Number
Group Number
Insurance Name
Policy Number
Group Number
Insurance Name
Policy Number
Group Number
2. SELECT A VACCINATION LOCATION
Location*
- Kauai Veterans Memorial Hospital
- Samuel Maheloha Memorial Hospital
3. PLEASE LET US KNOW ANY ADDITIONAL ACCOMMODATIONS YOU MIGHT NEED
Accommodations

1. CONTACT INFORMATION