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COVID-19 Vaccine Registration, Appointment & Consent Form
Name
*
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State Initials
Postal / Zip Code
Date of Birth
*
/
Month
/
Day
Year
Gender
*
Please Select
Male
Female
Race
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Ethnicity
*
Please Select
Hispanic or Latino
Not Hispanic or Latino
Unknown
Phone Number
*
Email
example@example.com
Eligibility
*
Please Select
Aged 18+ AND live in zip code 85201
Aged 18+ AND live in zip code 85202
Aged 18+ AND live in zip code 85203
Aged 18+ AND live in zip code 85204
Aged 18+ AND live in zip code 85210
Aged 18+ AND live in zip code 85256
Emergency Contact Name
*
Phone Number of Emergency Contact
*
COVID-19 Vaccine Screen Questions
*
Yes
No
1. Have you ever received a dose of COVID-19 Vaccine?
2. Have you ever had an allergic reaction to an injectable medication?
3. Have you ever had a severe allergic reaction to any medication?
4. Have you received any vaccine in the last 14 days?
5. Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19?
6. Have you been treated for COVID-19?
7. Do you take any medications?
8. Do you have any health conditions or disorders?
9. Are you pregnant or breastfeeding?
Please List Allergies Here:
Please List Medications Here:
Consent (check each box below after reading and prior to signing the form)
*
Check each box
I understand the benefits and risks of the COVID-19 vaccine. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me.
I understand that at this time, the COVID-19 vaccine requires 2 doses given 21-28 days apart depending on the manufacturer. If this is my second dose, I will bring my vaccine card with me to be completed.
I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.
I understand that I will be receiving the vaccination at no cost to me.
Please select one of the following that you will bring with you to your appointment.
Photo Identification
Driver's license
Select an appointment time
*
Signature of Person to Receive Vaccine:
*
Clear
Date Signed
*
/
Month
/
Day
Year
Date
Submit Consent Form (required)
Should be Empty: