COVID-19 Vaccine Registration Form
PLEASE FILL OUT ALL SPACES
Name
First Name
Last Name
Social Security Number
Birth Date
-
Month
-
Day
Year
Date
Gender
Female
Male
Email
example@example.com
Phone Number
Please enter a valid phone number.
Pharmacy Insurance Company
BIN/PCN/GROUP
Pharmacy Insurance ID
MEDICARE ID (From red, white and blue card)
Patient Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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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
High fever
Difficulty in breathing
Body aches
Runny nose
Diarrhea
Cough
Persistant pain or pressure on chest
Nasal congestion
Sore throat
Other
Have you been diagnosed with COVID-19?
Yes
No
If yes, please provide further details (date of diagnition, were you hospitalized or not, treatment, etc.)
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Have you ever received a dose of COVID-19 vaccine?• If yes, which vaccine product did you receive?
Please Select
P-fizer-BioNTech
Moderna
Janssen (Johnson&Johnson)
Other
Have you received a complete COVID-19 vaccine series
Please Select
YES
NO
Make sure you bring your vaccine record to your appointment
What is the date of your last dose of the Covid Vaccine? (It needs to be 6 months at least from second dose to be able to get 3rd dose)
-
Month
-
Day
Year
Date
I hereby declare that all the given information are accurate.
YES
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COVID-19 Vaccine Consent Form
Please read below carefully and ask for help if you need
The COVID-19 vaccine will reduce the risk of being suffering from the new type of Coronavirus disease as known as COVID-19. Please be aware that the vaccine is not completely effective like all other medicines. It can take a few weeks for your body to build up protection from the vaccine. There is always a chance to get infected by Coronavirus even with the vaccine; however, the vaccine lessens the severity of any infection. Two doses will reduce the chance of being seriously ill and reduce the risk of death due to Coronavirus. You still need to follow the health instructions in your workplace and in public areas, such as wearing a mask and keeping the distance from others after you received the COVID-19 vaccine. The vaccine has some side effects as the other vaccines/medicines, but not everyone gets them. The most likely side effects that you may experience from the vaccine Fever Pain at the injection site Redness and hardness of the skin at the injection site Headache Muscle aches or pain Joint aches or pain Fatigue (tiredness) Nausea/vomiting Chills Underarm gland swelling on the side of study vaccination If you think you are experiencing any side effects, please remain calm and see your doctor immediately. If you are currently pregnant or planning to get pregnant or your partner is planning to get pregnant; please see your doctor before getting vaccinated.
Do you have allergies to latex, food, medications, or vaccine components? (such as eggs, thimerosal, gelatin, neomycin, phenol, or bovine protein)?
Please Select
YES
NO
DONT KNOW
Did you ever experience any serious reaction after getting a vaccine?
Please Select
YES
NO
DONT KNOW
In the past year, did you receive a transfusion of blood or blood products, or get injected immune (gamma) globulin or any antiviral drug?
Please Select
YES
NO
DONT KNOW
Did you have any brain or other nervous system problems?
Please Select
YES
NO
DONT KNOW
Have you get vaccinated in the last 4 weeks?
Please Select
YES
NO
DONT KNOW
Are your pregnant or planning to get pregnant or your partner is planning to get pregnant?
Please Select
YES
NO
DONT KNOW
Do you have any of the followings? (select all that apply)
Lung disease
Heart disease
Asthma
Kidney Disease
Diabetes
Anemia
Blood disorder
NONE
Do you have immunocompromised condition? (select all that apply)
Cancer
Leukemia
Lymphoma
HIV/AIDS
Transplant
Asplenia
CSF leak
Cochlear implant
None
In the last 14 days, have you contacted with a person who was confirmed to have COVID-19?
Please Select
YES
NO
DONT KNOW
In the last 14 days, have you travelled internationally?
Please Select
YES
NO
Do you have any of the followings?
Cough
Cold
Fever
Shortness of breath
Sore throat
Loss of smell/taste
Abdominal pain/diarrhea
Abnormal bruising or bleeding/eye redness
EMERGENCY CONTACT
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
By signing this form, I hereby accept that I have read and understood the acknowledgment letter provided above. I declare that the information I have provided above is correct. I am giving my full consent to get the COVID-19 vaccine of my own will.
Signature
Clear
Date
-
Month
-
Day
Year
Date
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READ FOR INFORMATIONAL PURPOSES ONLY DO NOT HAVE TO FILL OUT
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Appointment
Please read Fact sheets and V-Safe forms before coming in for appointment
PFIZER EUA FACT SHEET
MODERNA EUA FACT SHEET
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