COVID-19 Testing/Vaccine Registration Form

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. A complete vaccine series (including a booster vaccine) 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 vaccination

If you think you are experiencing any side effects, please remain calm and see a physician immediately or call 911.

By signing this form, I hereby acknowledge that I have read and understand the information provided above. I declare that the information I have provided above is true and correct. I am giving my full consent to get the following service/s (if under the age of 18, legal guardian must consent):*

Covid-19 VaccineCovid-19 Rapid Antigen testCovid-19 Rapid Antigen test AND Covid-19 Vaccine

Please sign electronically. If patient is under 18, please have legal guardian sign.*

Today's Date

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Do you have allergies to latex, food, medications, or vaccine components? (such as eggs, thimerosal, gelatin, neomycin,phenol, or bovine protein)?
Have you ever experienced any serious reaction after getting a vaccine?
Do you have any brain or other nervous system problems?
Do you have any immunocompromising conditions? (i.e. cancer, HIV/AIDS, Transplant)

COVID-19 Testing/Vaccine Registration Form

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