Get Ready Vaccine Patient Intake Form

Is this your first or second dose of the COVID-19 Vaccine? *

First Dose Second Dose

If this is your second dose, which does did you take?

Moderna Pfizer Janssen Don't Know N/A

If this is your second dose, what date did you take your first dose

Date

Have you been diagnosed with COVID-19? *

Yes No

Do you have a weakened immune system? *

Yes No Don't Know

Are you pregnant or breastfeeding? *

Yes No Don't Know

In the past two weeks, have you tested positive for COVID-19 or are you currently being monitored for COVID-19 *

Yes No Don't Know

Have you received any vaccine in the last 14 days? *

Yes No Don't Know

In the past two weeks, have you had contact with anyone who tested positive for COVID-19? *

Yes No Don't Know

Have you received monoclonal antibodies or convalescent plasma as part of a COVID-19 treatment in the past 90 days?

Yes No Don't Know

Do you have severe allergic reactions to injections, latex or food? (This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives,swelling, or respiratory distress, including wheezing). *

Yes No Don't Know

Have you ever had a serious reaction after receiving a vaccination? Do you have a history of fainting, particularity with vaccines? Has any physician or other healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a medical setting? *

Yes No Don't Know

Do you have a bleeding disorder or are you taking a blood thinner? *

Yes No Don't Know

Please select an available date to the right of the calendar. *

Please list your current medication

Please list down your allergies

I hereby declare that all the given information are accurate. *

I Agree

CONSENT FOR SERVICES - I have been provided with the Vaccine Information Sheet(s) or patient fact sheet corresponding to the vaccine(s) that I am receiving. I have read the information provided about the vaccine I am to receive. I have had the chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of vaccination and I voluntarily assume full responsibility for any reactions that may result. I understand that I should remain in the vaccine administration area for 15 minutes after the vaccination to be monitored for any potential adverse reactions and 30 minutes if you have a history of anaphylaxis. I understand if I experience side effects that I should do the following: call pharmacy, contact doctor, call 911. I request that the vaccine be given to me or to the person named above for whom I am authorized to make this request. I do hereby authorize Ready Nursing Solutions Inc. to release information and request payment. I certify that the information given by me in applying for payment under Medicare or Medicaid, or the HRSA COVID-19 Program for Uninsured Patients, is correct. I authorize release of all records to act on this request. I request that payment of authorized benefits be made on my behalf. *

Clear

DISCLOSURE OF RECORDS: I understand that Ready Nursing Solutions Inc, may be required to or may voluntarily disclose my health information to the physician responsible for this protocol of specific health information of people vaccinated at Ready Nursing Solutions (if applicable), my Primary Care Physician (if I have one), my insurance plan, health systems and hospitals, and/or state or federal registries, for purposes of treatment, payment or other health care operations (such as administration or quality assurance). I also understand that Ready Nursing Solutions Inc, will use and disclose my health information as set forth in the Ready Nursing Solutions Inc Notice of Privacy Practices that is available by requesting a paper copy. If I am receiving a vaccine through a vaccine clinic, I understand that my name, vaccine appointment date and time will be provided to the clinic coordinator. *

Clear

Please select an available time slot to the right. *

CONSENT FOR SERVICES - I have been provided with the Vaccine Information Sheet(s) or patient fact sheet corresponding to the vaccine(s) that I am receiving. I have read the information provided about the vaccine I am to receive. I have had the chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of vaccination and I voluntarily assume full responsibility for any reactions that may result. I understand that I should remain in the vaccine administration area for 15 minutes after the vaccination to be monitored for any potential adverse reactions and 30 minutes if you have a history of anaphylaxis. I understand if I experience side effects that I should do the following: call pharmacy, contact doctor, call 911. I request that the vaccine be given to me or to the person named above for whom I am authorized to make this request. I do hereby authorize Ready Nursing Solutions Inc. to release information and request payment. I certify that the information given by me in applying for payment under Medicare or Medicaid, or the HRSA COVID-19 Program for Uninsured Patients, is correct. I authorize release of all records to act on this request. I request that payment of authorized benefits be made on my behalf.

DISCLOSURE OF RECORDS: I understand that Ready Nursing Solutions Inc, may be required to or may voluntarily disclose my health information to the physician responsible for this protocol of specific health information of people vaccinated at Ready Nursing Solutions (if applicable), my Primary Care Physician (if I have one), my insurance plan, health systems and hospitals, and/or state or federal registries, for purposes of treatment, payment or other health care operations (such as administration or quality assurance). I also understand that Ready Nursing Solutions Inc, will use and disclose my health information as set forth in the Ready Nursing Solutions Inc Notice of Privacy Practices that is available by requesting a paper copy. If I am receiving a vaccine through a vaccine clinic, I understand that my name, vaccine appointment date and time will be provided to the clinic coordinator.

(Internal Only) Reschedule date.

Date

DISCLOSURE OF RECORDS: I understand that Ready Nursing Solutions Inc, may be required to or may voluntarily disclose my health information to the physician responsible for this protocol of specific health information of people vaccinated at Ready Nursing Solutions (if applicable), my Primary Care Physician (if I have one), my insurance plan, health systems and hospitals, and/or state or federal registries, for purposes of treatment, payment or other health care operations (such as administration or quality assurance). I also understand that Ready Nursing Solutions Inc, will use and disclose my health information as set forth in the Ready Nursing Solutions Inc Notice of Privacy Practices that is available by requesting a paper copy. If I am receiving a vaccine through a vaccine clinic, I understand that my name, vaccine appointment date and time will be provided to the clinic coordinator.

COVID-19 Vaccine Patient Intake Form

COVID-19 Questions