Pre-Dose Health Assessment
Please complete this assessment to help us ensure your safety before your scheduled dose.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have any known allergies?
*
No known allergies
Yes (please specify)
Are you currently taking any medications?
*
No
Yes (please list)
Have you experienced any of the following symptoms in the past 48 hours? (Select all that apply)
*
Fever
Cough
Shortness of breath
Rash
None of the above
Other (please specify)
Please provide any additional relevant medical history or information that may affect your dose (optional)
Submit Assessment
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