COVID-19 Vaccination Accept/Decline Form

COVID-19 Vaccination Accept/Decline Form
If you already received the COVID-19 vaccine from other health facility, let us know and provide a document or a proof of vaccination.
Name
First NameLast Name
Age
Gender
MaleFemale
Date of Birth
MonthDayYear
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Do you accept or decline receiving the COVID-19 vaccination?
I acceptI decline
What is the reason why you're refusing to be vaccinated against COVID-19?
Reminders
I confirmed that ABC Health Care strongly recommended me to accept the COVID-19 Vaccine.
I confirmed that this health institution educated me about COVID-19, the advantages of receiving the vaccine, and the issues that might happen if I decline.
I understand that COVID-19 is a contagious virus that can spread easily from one person to another.
I understand that I can have COVID-19 and experience no symptoms at all but I can still transmit it to others.
I understand that if I get positive with COVID-19, I'll be isolated as per the local government health protocols.
Signature
Clear
Date Signed
MonthDayYear
Date
Should be Empty:

Reminders