Access My Profile

Please login below using your confirmation code and date of birth. To schedule your COVID-19 vaccine appointment, you will need a profile in the system. Don't have a profile? Click here to create one.

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Vaccine Registration
Current Registration Details

You are not currently scheduled to receive a COVID-19 vaccine. Please choose an appointment below.

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Vaccine Registration
Personal Information
First Name
Middle Name
Last Name
Birthdate
Gender
Address Information
Address
Zip Code
City
County
Contact Information

You will be contacted using one or more of the following methods. We recommend that you select at least one of email and text/SMS, so that any correspondence about your vaccination will be automatically archived.

Mobile Number
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Email Address
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Emergency Contact
First Name
Last Name
Phone Number
Are you homebound due to transportation, health, or disability?
Do you have a disability and need accomodation?
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Vaccine Registration
Demographics
Primary Language
Race
Ethnicity
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Vaccine Registration
Insurance Information
Do you have any form of medical insurance?
Alternate Care Access
Do you access care from any of the following services?
Billing Consent
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Medical Screening Questions

Are you sick today?

Please explain:

Do you have allergies to medications, food, a vaccine component, or latex?

Please list:

Have you ever had a serious reaction after receiving a vaccine, including a prior dose of COVID-19 vaccine?

Please explain:

Do you have a bleeding disorder or are you taking a blood thinner?

Please explain:

Are you pregnant or is there a chance you could become pregnant during the next month?

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Are you nursing (breastfeeding) a child?

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Have you received any vaccinations in the past 14 days?

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Have you tested positive for COVID-19 in the last 10 days?

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Have you received a COVID-19 vaccine in the past?

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Do you have an immune-suppressing condition or medicine?

Please explain:

I have been given and have read or have had explained to me, the information in the FACT SHEET FOR RECIPIENTS AND CAREGIVERS (Pfizer | Moderna). I have had a chance to ask questions that were answered to my satisfaction. I believe I understand the benefits and risks of the vaccine requested and ask that the vaccine checked below be given to me or the person named for whom I am authorized to make this request. I request that payment of authorized benefits be made to the New Mexico Department of Health/Public Health Division/Immunization Program, for services furnished to me by that program. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services and its agents any information needed to determine these benefits payable for related services. I specifically authorize the release of my Medicare or other insurance policy number to the NM Department of Health to allow the Department of Health to seek reimbursement for the vaccine and administrative costs. Unless I sign a statement signifying otherwise, I allow immunization information to be entered into the New Mexico Statewide Immunization Information System (NMSIIS) and be released to other medical care providers to avoid unnecessary vaccination or to ascertain immunization status. The DOH Privacy Policies are available at http://nmhealth.org/hipaa.shtml and will be given to all patients when they receive an immunization.

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Employment Information
Employment Details
Employer Name
Occupation
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Registration Details
Next Steps

You are not currently scheduled to receive a COVID-19 vaccine. Please schedule an appointment.

In order to receive your COVID-19 vaccine, you must complete your profile. You do not have to complete your profile in one sitting; you may return to do so at a future date. You will need your confirmation code and date of birth.

Once you have completed your profile, you will be contacted by the Department of Health as soon as you are able to schedule an appointment. On the day of your appointment, the Department of Health will prompt you to fill out your medical questionnaire.

Please note that vaccine is limited. We appreciate your patience.

COVID-19 Vaccine Activity

Please indicate whether you have received any vaccine to date.

Intial Dose

Have you received your initial dose?
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Chronic Medical Conditions

Increased Risk Of Severe Illness

Might Be At Increased Risk

Other conditions
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