Access 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.

Enter Your Confirmation Code:
Enter Your Date of Birth: (MM/DD/YYYY)
Vaccine Registration
Appointment Details

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Vaccination History

Please list the approximate dates of your previous vaccinations.

Manage Children & Dependents

You may add or link a child or dependent profile to your own and manage it on their behalf. Create and link as many profiles as necessary. Once created and linked you'll be able to update profile info, schedule appointments, and complete parental consent forms.

Link an Existing Profile:
Dependent's Confirmation Code
Dependent's Date Of Birth
Create a New Profile:

If your dependent does not yet have a VaccineNM profile, you can create one for them here.

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Vaccine Registration
Personal Information
Legal First Name
Legal Middle Name
Legal Last Name
Birthdate
Gender
Address Information
Street 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
Re-Enter Mobile Number
Email Address
Re-Enter Email Address
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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Parent/Guardian Consent

I, Yo, , being the parent, guardian or legal representative authorized to consent to medical treatment for the minor child listed below, hereby consent and permit authorized medical providers of the New Mexico Department of Health ("NMDOH") to administer the vaccine to my child with or without my physical presence. padre, tutor o representante legal autorizado doy el consentimiento para el tratamiento médico del menor que se menciona a continuación y permito que los proveedores médicos autorizados del Departamento de Salud de Nuevo México ("NMDOH") administren la vacuna al niño nombrado a continuación con o sin mi presencia física. (El representante legal incluye cualquier tutor o guardián, o un adulto con una declaración jurada de cuidador debidamente ejecutada).

I understand that following delivery of the vaccine, NMDOH will observe my child.

  • If my child is unaccompanied by an adult, my child will be monitored for a 30-minute period for an adverse reaction.
  • If my child is accompanied by an adult, my child may be released to the care of the adult after a 15-minute period for an adverse reaction.
  • If my child has a medical condition increasing their risk of a reaction, my child will be monitored for a 30-minute period for an adverse reaction.

Entiendo que después de la administración de la vacuna, el NMDOH observará al niño.

  • Si el menor no está acompañado por un adulto, el niño será vigilado durante un periodo de 30 minutos para detectar una reacción adversa.
  • Si el niño está acompañado por un adulto, puede ser entregado al cuidado del adulto después de un período de 15 minutos de observación de una reacción adversa.
  • Si el menor tiene una condición médica que aumente el riesgo de una reacción, el niño será monitoreado por un período de 30 minutos para detectar una reacción adversa.

Should a reaction occur, I authorize any necessary emergency medical treatment and understand that NMDOH will notify me as soon as possible. I further acknowledge that this consent may be verified either in person or verbally by telephone before the vaccine is administered if there are questions.

Si se produce una reacción, autorizo cualquier tratamiento médico de emergencia necesario y entiendo que el NMDOH me notificará lo antes posible. Además, reconozco que este consentimiento puede ser verificado en persona o verbalmente por teléfono antes de la administración de la vacuna si hay preguntas.

I understand that my child will receive a vaccine approved by the Food and Drug administration under an Emergency Use Authorization.

Entiendo que el menor recibirá una vacuna aprobada por la Administración de Alimentos y Medicamentos bajo una Autorización de Uso de Emergencia.

I have been given access to the "FACT SHEET FOR RECIPIENTS AND CAREGIVERS" for the Vaccine:

He tenido acceso a la " HOJA INFORMATIVA PARA RECIPIENTES Y CUIDADORES " de la vacuna :

I understand the benefits and risks of vaccination and I give permission for child to be vaccinated.

Entiendo los beneficios y riesgos de la vacuna y doy permiso para que el niño sea vacunado.

Vaccine Being Administered Vacunación que se administra
Name of minor receiving vaccine: Nombre del menor que recibe la vacuna:
Confirmation Number of minor: Número de confirmación del menor:
Name of parent of legal guardian: Nombre del padre, tutor o representante legal:
Relationship to the child: Relación al menor:
Home phone # of parent or legal guardian: Teléfono de casa o del trabajo del padre, tutor o representante legal:

To sign this Consent Form, please type your full legal name. Your typewritten name will be recognized as your signature and approval of this Consent Form.

Signature of parent of legal guardian: Firma del padre, tutor o representante legal:
Date: Fecha:
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:

Have you received monoclonal antibody or convalescent plasma for COVID-19 treatment in last 90 days?

Please explain:

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

Please explain:

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

Please explain:

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 (). 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.

Vaccine Interest
Are you still interested in receiving a COVID-19 Vaccine?
What language do you prefer?
Chronic Medical Conditions

Increased Risk Of Severe Illness

Might Be At Increased Risk

Other conditions
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