COVID-19 Vaccine Registration Form
Social Security Number
Please enter a valid phone number.
Street Address Line 2
State / Province
Postal / Zip Code
Insurance Company (if available)
Insurance ID (if available)
Health and Medical History
Do you have any chronic health condition?
Please indicate all health issues that are considered within the risk group
Please list your current medication
Please list down your allergies
Please check the symptoms that apply
Loss of taste or smell
Difficulty in breathing
Persistant pain or pressure on chest
Have you been diagnosed with COVID-19?
If yes, please provide further details (date of diagnition, were you hospitalized or not, treatment, etc.)
I hereby declare that all the given information are accurate.
Should be Empty: