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.
Last Name *
First Name *
Date Of Birth *
MM
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DD
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YYYY
Sex *
Race *
Hispanic Ethnicity *
Address *
City *
County of Residence *
State *
Zip Code *
Preferred Phone Number *
Email *
Select at least one that applies *
Select all the apply
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? *
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? *
Have you received any other vaccines in the last 14 days? *
Are you breastfeeding or pregnant? *
Have you received passive antibody therapy as a treatment for COVID-19? *
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) *
Do you have a bleeding disorder or are you taking a blood thinner? *
Have you ever received a dose of COVID-19 vaccine? *
Once form is completed and submitted, it will be reviewed. After review you will receive a voice or text message with your appointment date and time.
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