Autism NJ- Vaccine Pre-Registration

Please read carefully
Note that failure to complete steps as outlined or providing inaccurate responses to questions on this form can result in delaying or declining your appointment request.
Agreement*
I agree with the following terms
Terms:
I understand that completing this form will not guarantee that a vaccination or booster shot appointment will be made for me.

I understand that my information will be stored on the Autism New Jersey website and shared only with Visiting Nurse Association of Central Jersey Community Health Center.

I understand that my contact information will be added to Autism New Jersey's mail list for emails about future opportunities with Autism New Jersey. I may unsubscribe from this list at any time.
CAPTCHA

Contact Person's Information
Contact Person's Name*
First Last
Contact Person's Email*
Enter Email Confirm Email
Contact Person's Mobile Phone*
We may contact you by text with appointment information.
Relationship to Patient*
Describe your relationship to the patient*
Patient Information
Patient's Name*
First Last
Patient's Date of Birth*
No pediatric shots are available to patients under age 12 at this time.
Month
Day
Year
Please select the vaccination type you are seeking for the patient*
- First shot
- Second shot
- Booster shot

Accommodation Requests

For those with special needs, the clinic has made several accommodations that include: designated parking, a special needs check-in station, limited wait times, and special access to avoid public waiting areas.

The nurses and medical staff will provide the vaccine in the safest and most accommodating way possible. However, they are NOT trained and cannot participate in any hold.

If you feel the patient requires to be physically held, you will need to do so. Additional staff will not be available to assist. It is your responsibility to bring adequate support.

If you have any questions, please email: vaccine@autismnj.org

To help us support you, please answer the following questions:
Does the patient have trouble wearing a mask?*
- Yes
- No
Please explain*
Will the patient need supports to receive the vaccine?*
- Yes
- No
Please explain*
Do you prefer an in-car vaccination?*
The site is equipped to assist individuals that would benefit from this accommodation.
- Yes
- No
Any requested accommodations not listed above
Requested accommodations will be passed along to the vaccination site. The site will try to fulfill reasonable accommodation requests, but it is not guaranteed. Upon approval and scheduling of your appointment, you will get detailed instructions on what to bring and expect for the day-of.
Additional appointments available
For your convenience, the site can also provide vaccines for you or other family members (who do not need special accommodations) during this appointment slot.
Check this box if you would like to schedule an additional appointment.
- Yes
Look for additional instructions to follow after we confirm the patient's clinical needs can be met by the site. Appointments must be scheduled together.
Certification*
I certify that my responses to this form are true to the best of my knowledge

Special Needs Vaccine Pre-Registration

Please read carefully

Contact Person's Information

Patient Information

Accommodation Requests

To help us support you, please answer the following questions:

Stay connected!