Mpox Vaccine Screening and Consent Form
Please complete the following screening questions and provide your consent for the Mpox vaccine.
Full Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Have you ever had a severe allergic reaction (anaphylaxis) to any vaccine or injectable medication?
Yes
No
Do you have a history of any of the following medical conditions? (Select all that apply)
Immunocompromised
Pregnant
Breastfeeding
Severe allergies
None of the above
Are you currently feeling unwell or have any symptoms of illness?
Yes
No
Have you received any vaccines in the past 14 days?
Yes
No
Consent for Vaccination
I hereby consent to receive the Mpox vaccine and acknowledge that I have been informed about the benefits and risks of the vaccine.
Yes
No
Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: