COVID-19 Vaccine Pre-Registration/Consent
Once you submit this form, you will receive an call and/or text with your appointment time once we have vaccine available for you.
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Last Name *
First Name *
Date Of Birth *
MM
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DD
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YYYY
Sex *
Race *
Hispanic Ethnicity *
Address *
City *
State *
Zip Code *
Preferred Phone Number *
Email *
Vaccine Preference *
Select at all that apply *
Select all the apply
Required
What time slot works best for your schedule? *
Required
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 Epi Pen or for which you had to go to the hospital? Including: Polysorbate? *
Have you ever had a serious reaction after any vaccination of injectable medication including a previous dose of the COVID-19 vaccine? *
In the past 14 days have you had contact with a confirmed COVID-19 patient? *
Are you breastfeeding or pregnant? If you are, an order from your physician is required. *
Have you received passive antibody therapy as a treatment for COVID-19? If you have, it is required that you wait 90 days after your infusion for a vaccine. *
Are you immunocompromised? (taking medication or being treated for cancer, leukemia, HIV/AIDS or other immune system problems or taking medication that affects your immune system). You may qualify for a 3rd dose of vaccine. *
Do you have a bleeding disorder or are you taking a blood thinner? *
Once form is completed and submitted, it will be reviewed. After review you will receive an email with your appointment date and time. Please understand that this form is monitored by one nurse and is not checked multiple times a day. *
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