Please login below using your access 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.
Please list the approximate dates of your previous vaccinations.
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.
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.
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.
Entiendo que después de la administración de la vacuna, el NMDOH observará al niño.
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.
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.
Are you sick today?
Do you have allergies to medications, food, a vaccine component, or latex?
Have you ever had a serious reaction after receiving a vaccine, including a prior dose of COVID-19 vaccine?
Do you have a bleeding disorder or are you taking a blood thinner?
Have you received monoclonal antibody or convalescent plasma for COVID-19 treatment in last 90 days?
Have you tested positive for COVID-19 in the last 10 days?
Have you received a COVID-19 vaccine in the past?
Do you have an immune-suppressing condition or medicine?
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.
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 access 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.