COVID-19 Vaccine Information

IDATB has been working with the Health Department to provide COVID-19 Vaccines to the Tampa Bay community.

We are currently scheduling appointments for the Moderna vaccine at our office.

If you are interested in receiving the vaccine, please fill out the form below. *Please note you will have to be available to come back in 4 weeks (28 days) to receive your second dose.

    Are you an active patient of IDATB?*

    YesNo

    What is the name of your IDATB Provider?*

    Do you currently have insurance?*
    Our Patients will not receive a bill for the COVID-19 Vaccination.

    YesNo

    Will you be available to receive the second vaccine in 4 weeks?*

    YesNo

    Last Name:*

    First Name:*

    Middle Initial:*

    Date of Birth:*

    Mobile Phone Number (Parent or Guardian):*

    Email Address:*

    Address:*

    Apt/Room #:

    City:*

    State:*

    Zip:*

    Sex (Gender assigned at birth):*

    MaleFemale

    Primary Insurance Information:
    If your insurance does not require one of the fields given below, please enter NA into that field.

    Primary Insurance Carrier ID #:*

    Primary Insurance Carrier Group #:*

    Insurance Company:*

    Insurance Company Phone #:

    Insured's Name:*

    Relationship:*

    Insured's Date of Birth:*

    Secondary Insurance Information:
    If your insurance does not require one of the fields given below, please enter NA into that field.

    Secondary Insurance Carrier ID #:

    Secondary Insurance Carrier Group #:

    Insurance Company:

    Insurance Company Phone #:

    Insured's Name:

    Relationship:

    Insured's Date of Birth:

    Is this the patient's first or second dose of the COVID-19 vaccination?*

    FirstSecond

    If you have been scheduled for an appointment at Infectious Disease Associates of Tampa Bay’s office, please download, print and fill out the additional documents below, and bring with you on your scheduled appointment:

    Forms to read and keep for your own information: