COVID-19 Vaccine Pre-registration Form

We are currently acting working on securing the best way we can in letting each and everyone have a vaccine against COVID-19. Please complete and submit this form below in order for us to identify the persons who would like to receive the vaccine. Please take note however that not everyone may be granted in receiving one. We will get in touch with you as soon as we can once we have a schedule for you.

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Date of Birth

Date

Are you categorized as immunocompromised (i.e. diabetic, suffering from heart, lung, or any metabolic or chronic disease, obese, pregnant, or of senior age)?

Have you received a placebo during the COVID-19 clinical trial?

Are you pregnant or intending to be pregnant in the next 6 months?

Are you allergic to eggs, vaccines, or any medicine?

Any additional information

Consent

Signature

Date

Name of Legal Guardian/Representative

First NameLast Name

Signature

Date