Vaccination - Registration- TotalWellness

Immunization Account Registration

Register prior to receiving your vaccination. Once registration is complete, you’ll receive an ID code that you should bring to your appointment.

* Indicates a required field

Company Code

First Name *

Last Name *

Date of Birth *

Parent/Guardian of a minor under the age of 19 must be present with the minor child the entire vaccination appointment regardless of allergy status.

Phone Number *

Accept Texts *

Sex *

Race *

Ethnicity *

Address Line 1 *

Address Line 2

City *

State *

Zip Code *

County

Do you have health insurance? *

Insurance Provider

Provider Name *

Member ID *

Group ID *

Primary Insured First Name *

Primary Insured Last Name *

Primary Insured Date of Birth *

Relationship To Primary Insured *

Primary Insured Employer

Card Front *

Card Back *

I would like to continue without creating an account

Email Address *

Email Confirmation *

Passwords must be at least 8 characters, have at least one digit ('0'-'9') and at least one uppercase ('A'-'Z').

Password *

Password Confirmation *