Kitsap COVID Moderna COVID 19 Vaccine Form (administered in Silverdale)
This is an add on form that you will be asked to fill out if you are adding on to a clinic without an appointment.
Please note, your second shot will be given exactly four weeks after your first shot at the same time and place as your first shot. You must be able to come to both times in order to get your shot.
Which shoulder will you have your shot in?*
Left Right
What county do you live in?*
Kitsap Mason Jefferson Clallam Other
We are only offering vaccines to Kitsap, Mason, Jefferson, or Clallam counties. Please check with your local department of health for vaccine clinics near you. Thank you.
Legal Name*
First Name Last Name
Date of Birth*
Month Day Year
Date
Please check your date of birth, it appears that you are under 16 years-old based on what you have filled in.
Cell Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Primary Care Provider
Sex listed at birth*
Male Female
Gender Identity
Male Female Non-binary Unspecified/Indeterminate
Ethnicity
Hispanic or Latino Not-Hispanic
Race (Check all that apply)
American Indian or Alaska Native Asian Black or African American Hawaiian or Pacific Islander White
Vaccine Dose*
1st dose 2nd dose
Which of these was your first dose:
Pfizer Moderna Unknown
We are giving the Moderna vaccine. We can't do second dose Pfizer vaccines at this time.
When did you receive your first dose:
Month Day Year
Date
Answering yes to either of these questions excludes you from receiving the vaccine.
Do you have a known history of a severe allergic reaction (e.g. anaphylaxis) to this vaccine or any components of the vaccine including lipids, tromethamine, tromethamine hydrochloride, acetic acid, sodium acetate, and sucrose. (Full list is available in the Fact Sheet for Vaccine Recipients and Caregivers or from your health care provider.)*
Yes No
Are you under the age of 18 years?*
Yes No
Additional screening questions
In the past two weeks have you tested positive for COVID-19?*
Yes No
In the past two weeks have you had exposure to a person who tested positive for COVID-19 at a distance of six feet or less for a period of 15 or more minutes without wearing appropriate personal protective equipment?*
Yes No
Have you had a new onset of fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, nausea, vomiting or diarrhea?*
Yes No
In the past 90 days have you received passive antibody therapy as part of COVID-19 treatment?*
Yes No
Are you pregnant or breastfeeding or do you plan to become pregnant?*
Yes Yes, I have spoken with my doctor and we have decided to get the shot No
Are you immune compromised or on a medicine that affects your immune system?*
Yes, I haven't spoken with my doctor Yes, but my doctor said that I should get the immunization anyway No
Do you have a bleeding disorder or are you on a blood thinner?*
Yes No
Do you have a history of severe allergic reaction (e.g. anaphylaxis) to another vaccine or injectable medication?*
Yes No
In the last two week or in the next two weeks do you plan on getting a different vaccination (shingles, flu, etc)
Yes No
It is not recommended that you obtain a COVID shot within two weeks or a different vaccination.
Acknowledgements:
---I made the choice to get the COVID-19 vaccine on my own and freely. I know I have the option to refuse the vaccine. I ask that the vaccine be given to me, or to the person named above for whom I can make this request. Upon request I will be given (Fact Sheet for Vaccine Recipients and Caregivers) which has information about side effects and adverse reactions. I read or had read to me the information provided about the COVID-19 vaccine. ---I know the Food and Drug Administration (FDA) has authorized the emergency use of this vaccine. I know it is not a fully licensed FDA vaccine. I had the chance to ask questions that were answered to my satisfaction. I now know about the vaccine, alternatives, benefits, and risks, to the extent they are known and unknown at this time. ---I know that I must stay in the vaccine area or an area told to me by my health care provider after I receive my immunization so I am near my health care provider if I have any adverse reactions. If I have a history of severe allergic reaction, (e.g. anaphylaxis), I must stay for 30 minutes. If I do not have a history of severe allergic reaction, I must stay for 15 minutes ---I know that if I have a severe allergic reaction, including difficulty breathing, swelling of my face and/or throat, a fast heartbeat, a bad rash all over my body or dizziness and weakness I should call 9-1-1 or go to the nearest hospital. I know I can call my health care provider if I have any side effects that bother me or do not go away. ---I was asked to join the V-SAFE program. The program does health checks on the people who get the COVID-19 vaccine. I know I should report vaccine side effects to FDA/CDC Vaccine Adverse Event Reporting System (VAERS) at 1-800-822-7967 or https://vaers.hhs.gov/reportevent.html. ---I know I must get two doses of the COVID-19 vaccine and receive the same vaccine each time. I know that with all vaccines there is no promise I will become immune (not get the virus) or that I will not have side effects. I know I may choose to not get the second dose of the vaccine. But if I do not get the second dose, the chance that I will become immune may go down. ---Authorization to Request Payment: I authorize the organization providing my vaccine to release information and request payment. I certify that the information given by me in applying for payment under Medicare or Medicaid or the HRSA COVID-19 Program for Uninsured Patients, is correct. I authorize release of all records to act on this request. I request that payment of authorized benefits be made on my behalf. ---Disclosure of Records: I understand the organization providing my vaccine may be required to or may voluntarily disclose my vaccine-related health information to my primary care physician, my insurance plan, health systems and hospitals, and state or federal registries or other public health authorities, for purposes of treatment, payment or health care operations. I also understand the organization providing my vaccine will use and disclose my health information as described in its Notice of Privacy Practices which I may receive upon request or find on its website.*
Clear
Unfortunately we are unable to offer you a COVID vaccine due to your medical history and would encourage you to seek vaccination through the hospital or your primary doctor. Thank you.
You should get an email from us giving you the location of the injection and confirming your appointment time. If you think there was an error in the form which hasn't allowed you to fill it out, please email kitsapcovid@gmail.com. Thank you.
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