Medical Verification Form For COVID-19 Vaccine

Medical Verification Form For COVID-19 Vaccine
- Name
  First NameMiddle NameLast Name
- Date of Birth
  MonthDayYear
  1
- Age
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Email
  example@example.com
- Medical Conditions
  - Cancer
  - Chronic Kidney Disease
  - COPD (Chronic Obstructive Pulmonary Disease) and
    other high-risk pulmonary disease
  - Down Syndrome
  - Heart Conditions, such as heart failure, coronary
    artery disease, or cardiomyopathies
  - Immunocompromised states
  - Obesity (body mass index of 30 kg/m or higher)
  - Pregnancy
  - Sickle cell disease
  - Type 2 Diabetes Mellitus
  Note: This list does not contain every condition that might increase one’s risk for developing severe illness from COVID-19, such as those for which evidence may be limited (e.g., rare conditions or combinations of conditions). The health care provider is allowed to vaccinate any patient assessed to have significant risk for severe illness due to comorbidities, even if not listed here.
- Since the patient described above has two or more medical conditions, it may put the patient at significantly increased risk for severe COVID-19 infection or death.Since the patient described above is a family caregiver of a child under 16 who has two or more medical conditions, it may put the child at significantly increased risk for severe COVID-19 infection or death.Other
- Health Care Provider
  First NameLast Name
- License #
  or NPI
- Provider
  Provider FacilityPractice Name
- Address
  CityState / Province
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Date
  MonthDayYear
  Date
- Signature
  Clear
- Should be Empty: