Covid-19 Vaccination Request Form

Covid-19 Vaccination Request Form

13336 S Baltimore Avenue Chicago, IL
PLEASE READ:

This form will secure a vaccination for your name only at our Covid Express Care locations only. This form will allow us to allocate a certain amount of vaccinations when available. Please fill out this form and share with any family members / friends. Please be patient; When your turn comes, we will contact you immediately!

THIS FORM IS A SECURE HIPAA COMPLAINT FORM.
Name

First Name Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Are you pregnant, breastfeeding, or have plans to be pregnant in the next three months?

Yes No
Have you had an X-ray treatments in the past 3 months?Did you undergo an X-ray treatments in the last 3 months?

Yes No
Are you currently under medication?

Yes No
Do you have allergies or hypersensitivity to eggs, any known vaccine, or drugs, insects, seafood, etc.?

Yes No
Please provide details regarding your allergies or hypersensitivity
I confirm that I do not have or not experiencing:

Fever Cough Runny nose Sore throat Loss of taste or smell Shortness of breath
I declare that:

I have not traveled outside the country in the past 14 days I have not been exposed or been near to someone infected with COVID-19 I understand that in case I receive any information of me having possible exposure, I shall notify the committee as early as possible.
By signing this form, I acknowledge that I have received information with regard to the vaccine's risks and benefits. I have had the opportunity to ask questions and have received the answer to my satisfaction. I am giving my full consent and requesting for administration for vaccination.
Name of Patient

First Name Last Name
Signature

Clear
Date

Month Day Year
Date
Should be Empty:

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