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新冠疫苗注册登记表 Covid-19 Immunization Registration Form
此次活动由光盐社,殷正男医生诊所,亚裔健康教育协会,华人圣经教会,休斯顿华裔护理协会,中华老人服务协会合办
时间:2021年6月5日
地点:6025 Sovereign Dr., Houston, TX 77036
This event was hosted by Zhengnan Yin MD, PhD, Health Education for Asian League of Houston, Chinese Bible Church, Light and Salt Association, Chinese Nursing Association, and Chinese Seniors Association of Houston
Date: June 5th, 2021
Address: 6025 Sovereign Dr., Houston, TX 77036
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姓/Last Name *
名/First Name *
性别/Gender
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生日/Date of Birth
地址/Address
电话号码/Phone Number *
电子邮件/Email
疫苗种类/Vaccine Brand
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第一次疫苗注射还是第二次疫苗注射/1st dose or 2nd dose
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是否有医疗保险/Do you have Insurance? *
保险公司名字/Insurance Company Name
保险卡号码/Insurance Member ID
族裔/Race
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Before you receive the vaccine, please inform us if you have a history of serious allergy. 如果您有严重过敏反应的病史,请在接种疫苗前告知我们。You are not eligible for Covid-19 vaccination if any of the following applies to you:(1) You are currently having a fever; (2) You were infected with covid-19 within the last 3 months; (3) You were treated for Covid-19 infection with passive antibody therapy(4) You have already received Covid-19 vaccine somewhere. 如果您有下述情况,应该考虑推迟接种疫苗(1)正在发热(2)3个月内感染过新冠病毒(3)感染新冠病毒期间接受过免疫治疗(4)您已经在其它地方接受了新冠疫苗。 *
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