**** Please do not fill this form out until it is the day you want to come for the vaccine, or the information will no longer be accurate ****
** If this is your first time receiving a vaccine from us, please also fill out the HIPAA Card**
Please check below which vaccine you are receiving today (either Pfizer or Moderna)?
Have you ever had an allergic reaction to any of the following? (This includes a severe allergic reaction (anaphylaxis) that required an EpiPen or going to the hospital. It also includes an allergic reaction within 4 hours that caused hives, swelling, or wheezing).