Hope Pharmacy COVID-19 Vaccine Registration Form
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  • Spanish (Latin America)

  • Hope Pharmacy COVID-19 Vaccine Form

    If completing for others, please enter information for each patient.
  • Appointment*
  • This is my First, Second, or Third dose of the COVID-19 Vaccine:*
  • Which vaccine are you requesting*
  • Date of Birth *
     - -
  • Format: (000) 000-0000.
  • By completing these fields you are attesting that you are 5+ years of age or older?*
  • Parent or Legal Guardian Date of Birth (Only applicable if patient is 18 years of age or younger)
     - -
  • Are you someone that (please check all that apply)*
  • Please review and check ALL the boxes below*

  • People younger than 18 years must have parental or guardian consent, unless patient is an emancipated minor. Learn more.

  • Health Insurance

  • Health Insurance - Do you have health coverage? The COVID-19 vaccine is free for everyone. Health insurance is not required. If you do not have health coverage, select No. If you do have health coverage, select Yes and your insurance will pay the vaccine provider for administering the vaccine- at no cost to you. You will not be charged or billed by your insurance.*

  • COVID-19 Vaccine related information

  • Are you feeling sick today?*
  • Have you been diagnosed with Multisystem Inflammatory Syndrome (MIS-C orMIS-A) after a COVID-19 infection?*
  • Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?*

  • Allergic reaction information

  • Have you ever had an allergic reaction to (1) component of the COVID-19vaccine, including polyethylene glycol (PEG), which is found in somemedications, such as laxatives and preparations for colonoscopy procedures, (2)Polysorbate, (3) a previous dose of COVID-19 vaccine (This would include asevere allergic reaction (e.g., anaphylaxis) that required treatment withepinephrine or EpiPen® or that caused you to go to the hospital. It would alsoinclude an allergic reaction that occurred within 4 hours that caused hives,swelling, or respiratory distress, including wheezing.)*
  • Have you ever had an allergic reaction to another vaccine (other than COVID-19vaccine) or an injectable medication? (This would include a severe allergicreaction (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 reactionthat occurred within 4 hours that caused hives, swelling, or respiratory distress,including wheezing.)*
  • Have you ever had a severe allergic reaction (e.g., anaphylaxis) to somethingother than a component of the COVID-19 vaccine, polysorbate, or any vaccine orinjectable medication? This would include food, pet, environmental, or oralmedication allergies.*
  • Do you have a weakened immune system caused by something such as HIVinfection or cancer or do you take immunosuppressive drugs or therapies?*

  • Health Conditions

  • Do you have a bleeding disorder or are you taking a blood thinner?*
  • Do you have a history of heparin-induced thrombocytopenia (HIT)?*
  • Are you pregnant or breastfeeding?*
  • Have you received dermal fillers?*
  • Do you have a history of myocarditis or pericarditis?*

  • ADA Requirements

  • State and federal nondiscrimination laws require medical providers to make sure that people with disabilities have the same access to medical care as people without disabilities. Please let us know if you require one or more of the following accommodations at your vaccine appointment. Check as many as apply.*

  • Please review the following:

    Pfizer EUA Fact Sheet - http://labeling.pfizer.com/ShowLabeling.aspx?id=14472

    Moderna EUA Fact Sheet - https://www.fda.gov/media/144638/download

    Johnson & Johnson Fact Sheet - https://www.fda.gov/media/146305/download

    V-Safe Registration - Get vaccinated. Get your smartphone. Get started with v-safe. (cdc.gov)

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