Covid Vaccine Registration Form
Completion of this form is required before scheduling an appointment with Madeleine C Weiser MD, PC
Email *
Patient First Name *
Patient Last Name *
Patient Date of Birth *
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Patient Gender assigned at birth *
Race (required for state reporting) *
Ethnicity (required for state reporting) *
Insurance Company Name *
Insurance ID Number (if no insurance type 0) *
Full Name of Subscriber for Insurance (if different from the patient)
Date of Birth of Subscriber (if different from the patient)
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Patient's Primary Care Doctor (if part of a Nemours practice, please type Nemours)
Mobile Phone Number *
Street Address (example: 123 Apple Way) *
City, State, Zip (example: Ardmore, PA 19003) *
Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something? For example, a reaction for which you were treated with epinephrine or EpiPen, or for which you had to go to the hospital? *
Do you carry an Epipen? (If yes, please bring it with you and inform the office at check in. You will need to wait 30 minutes after your vaccine instead of 15 minutes.) *
Have you received passive anitbody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? IF YES, YOU NEED TO WAIT 90 DAYS FROM THAT TREATMENT TO RECEIVE YOUR VACCINE. *
Have you been hospitalized for COVID-19 in the last 30 days? *
Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppresive drugs or therapies? *
Do you have a bleeding disorder or are you taking a blood thinner? *
Are you pregnant or is there a chance you could become pregnant during the next month? *
Have you had a seizure or a brain or other nervous system problem or ever had Guillan-Barre Syndrome *
Required
Have you already received an initial dose of the COVID-19 vaccine? *
Have you received any other vaccines in the last 14 days? *
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) (www.cdc.gov/vaccines/covid-19/eua/index.html), a copy of which I was provided with this Consent and Release. I request the vaccine to be given to me/my child. I consent to, or give consent for, the administration of the vaccine(s) and the notification to the PA Department of Health that this vaccine was given. I fully release and discharge Madeleine C Weiser MD, PC (owner and employees) from any liability for illness, injury, loss or damage which may result there from. I authorize the release of any medical or other information necessary to process this claim. I understand that I should remain in the instructed location for 15 minutes for observation in case there is an adverse reaction. *
Name of person completing this form *
A copy of your responses will be emailed to the address you provided.
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