COVID-19 Immunization Screening and Consent Form

Date

Name *

First Name Last Name

Email

example@example.com

Phone Number *

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Date of Birth *

Date

Age

Marital Status

Single Married Separated Widowed Other

Insurance

Medicare Medicaid Uninsured Other

Have you participated in any COVID-19 Vaccine Trial? *

Yes No

Requested Vaccination *

Moderna (2 doses, booster available) Pfizer (2 doses, booster available) Janssen (1 dose, booster available) No Preference

What dose will this be for you? *

First Second Booster

Screening

	Yes	No
Have you been treated with antibody therapy for COVID-19 in the past 3 months?
Have you been exposed any person with COVID-19 in the past 14 days?
Have you been recommended by your physician to self-isolate for at least 14 days?
Have you been diagnosed to have COVID-19 in the past 3 months?
Have you ever had an allergic reaction such as hives or difficulty breathing, to any vaccines or shots?
Have you received any vaccine in the past 2-weeks other than for COVID-19?
Are you pregnant or planning to be pregnant?
Are you currently nursing or breastfeeding a child?
Do you have AIDS/HIV, cancer, leukemia or any condition that weakens the immune system?
Are you taking any medication that affect your immune system, such as chemotherapy drugs, cortisone, prednisone or other steroids, or undergoing radiation treatments?

Appointment *

By signing this form, I declare that the information I have provided above are true and correct to the best of my knowledge. I understand the risks involved in having the COVID-19 Vaccination. I understand that a COVID-19 vaccine requires two doses, with at least 20 days apart from each dose or one dose for the Janssen. In this regard, I shall ensure to comply with the scheduled dates for vaccination. I have been given an opportunity to ask questions in relation to COVID-19 and the immunization, which answers were given to me to my satisfaction I understand that it is my free prerogative to refuse or receive administration of the vaccine and all the consequences of the risks over this matter. In any case, I request that the COVID-19 vaccination be given to me. It is my responsibility to secure or determine whether my insurance policy covers the administration of the vaccine. In case not, I shall be responsible to pay for the costs in cash. Finally, I authorize the release of my health information as needed for public health purposes, including for reportorial purposes for vaccine registry.

Signature *

Clear