ONLINE FORM FINAL

Where would you like to get your COVID-19 Vaccination? *
Appointment Time
Appointment Date *

Month Day Year
Day Date
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Last 4 Digits of Social Security #
Age
Sex *
Ethnicity *
Phone # *
Email Address
example@example.com
Address *
City *
County *
State *
Zip *
Insurance *
Social Security #: *REQUIRED IF NO INSURANCE
Insurance Provider *
Policy Number
Group Number
Other Insurance Provider
Effective Date of Policy

Month Day Year
Date
Policy Holder's Name
Policy Holder's DOB
Relationship to Policy Holder
Other
Policy Holder's Address
ACKNOWLEDGEMENT, AUTHORIZATION, VACCINATION and HEALTH RELATED INFORMATION

* ALL QUESTIONS & STATEMENTS REQUIRE ANSWERS *
Has the patient tested positive for Coronavirus (COVID-19) in the past 90 days? *
Has the patient received monoclonal antibody therapy within the past 90 days? *
Has the patient had a steroid injection within the past 2 weeks? *
Has the patient ever received a COVID-19 vaccination? *
Manufacturer
If yes, Date Given

Month Day Year
Date
Does the patient have any long term health problems? *
Please list long term health issues here
Has the patient had a life threatening reaction to any injectable medication, a COVID-19 vaccine or to a vaccine component (example: eggs, thimeroal, gelatin or bovina protein)? *
Has the patient had a seizure or any other brain or other nervous system problems (i.e.Guillian-Bartt syndrome after receiving a vaccine)? *
For Women: Are you pregnant or considering getting pregnant in the next 3 months or are you currently nursing? *
I have read and understand the HIPAA/Privacy Policy for AMERICAN MEDICAL SCREENING, INC. which can be found in its entirety at americanmedicalscreening.org. I authorize to have any of my test results delivered to me by email, phone or text . I authorize AMERICAN MEDICAL SCREENING, INC. to release/share medical information and/or test results with my primary care physician (when provided), ADPH and/or the CDC.
Patient/Guardian Signature

Clear
Date

Month Day Year
Date
Guardian/Parent: (Print) If Applicable
Relationship to Minor
Should be Empty:

ACKNOWLEDGEMENT, AUTHORIZATION, VACCINATION and HEALTH RELATED INFORMATION