Home Healthcare Assessment Quiz

1st Part: Medical History

Please complete the following questions for the individual receiving the vaccine. If you answer "YES" to any of these questions, you may not be able to receive the COVID-19 vaccine.
Which vaccine are you interested in receiving?*

PfizerModernaJohnson & Johnson
Have you had a previous COVID-19 vaccine?*

YesNo
Date of previous vaccine

MonthDayYear
Have you had any vaccines within the last 14 days?*

YesNo
Have you ever had a severe allergic reaction to any vaccine, vaccine component, or injectable therapy?*

YesNo
Are you pregnant, breastfeeding, or planning to become pregnant?*

YesNo
Are you immunocompromised or receiving any immunosuppressive therapy?*

YesNo
Have you received monoclonal antibodies or convalescent plasma as part of COVID-19 treatment?*

YesNo
2nd Part: Contact Information

Please fill in your contact information and someone will call you to schedule your 1st dose.
Name*

FirstLast
Date of Birth*

MonthDayYear
Phone Number*
Address*

Street Address

Address Line 2

CityState / Province / Region

Postal / Zip CodeCountry
Email
Race*
Gender*

FemaleMale
By completing this form you agree that you consent to receiving the vaccination and are eligible.
Please verify that you are human*
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1st Part: Medical History