COVID-19 Vaccine Registration, Consent and Appointment Form

COVID-19 Vaccine Registration, Consent and Appointment Form
Screening
Are you a healthcare worker? (Category/Phase 1A)
Are you 65 or over? (Category/Phase 1B)
Are you 16 or older with at least one of the following chronic conditions?
cancer, chronic kidney disease, COPD, heart conditions, coronary artery disease or cardiomyopathy, solid organ transplantation, obesity, pregnant, sickle cell disease, type 2 diabetes mellitus
At the current time, you are not eligible to receive the COVID-19 vaccine.
Do you have an allergic reaction to the COVID-19 Vaccine?
Do you have an allergic reaction to any vaccine?
Do you feel sick today?
Have you experienced any of the following symptoms within 10 days?
fever, chills, shortness of breath, fatigue, muscle or body ache, loss of taste or smell
Have you had a positive COVID-19 test within 14 days?
Did you receive a previous dose of any COVID-19 vaccine?
Do you have a bleeding disorder or are you on a blood thinner/blood-thinning medication?
Are you immunocompromised or on a medicine that affects your immune system?
Patient Information
Name
First NameLast Name
Email

Confirmation Emailexample@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth
MonthDayYear
Date
Current Date
MonthDayYear
Date
Age
Address
Street Address
Street Address Line 2
CityState
Postal / Zip Code
County
Race
Ethnicity
Gender
Vaccine Scheduling
Please select the dose of the vaccine you are scheduling.
Appointment Date
Consent
Signature
Please verify that you are human
Administration
First Vaccine Administration Date
MonthDayYear
Date
Hour MinutesAM/PM Option
First Vaccine Site
First Vaccine Maker
First Vaccine Lot #
Manufacturer Code
Product Code
1st Dose Expiration Date
MonthDayYear
Date
1st Dose Administered By
Second Vaccine Date
MonthDayYear
Date
Hour MinutesAM/PM Option
Second Vaccine Site
Second Vaccine Maker
Second Vaccine Lot #
Manufacturer Code
Product Code
2nd Dose Expiration Date
MonthDayYear
Date
2nd Dose Administered By
Should be Empty:

COVID-19 Vaccine Registration, Consent and Appointment Form

Screening

At the current time, you are not eligible to receive the COVID-19 vaccine.

Patient Information

Vaccine Scheduling

Administration