COVID Vaccine Patient Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Sex(Required) Female Male Is Patient 12 years of age or older?(Required) Yes No Is Patient a Kids + Patient?(Required) Yes No Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Care Provider(Required) Email(Required) Has patient had a severe allergic reaction (anaphylaxis, trouble breathing) to any component of the vaccine, including lipid nanoparticles or polyethylene glycol (PEG)?(Required) Yes No Has patient had a severe allergic reaction (anaphylaxis, trouble breathing) to other vaccines or injectable medications?(Required) Yes No Has patient...?(Required) Tested positive for COVID-19 in the last 10 days? Received convalescent plasma for COVID-19 in the past 90 days? Received monoclonal/polyclonal antibody infusions for COVID-19 in the past 90 days? None of the above Are you...? (Please check all that apply.)(Required) Pregnant Breastfeeding Sick (fever, chills, cough, fatigue, and/or body aches) In quarantine for COVID-19 exposure Taking blood thinners Suffering from a bleeding disorder None of the above Consent for Vaccination(Required) I certify that:+ I have answered these questions accurately. + I will notify my primary care provider if I experience adverse reactions after leaving the vaccination site. + I will review the Emergency Use Authorization Fact Sheet given to me at my vaccination appointment. + I understand the benefits and risks of the vaccine. + I am either the patient (18 years or older) or the parent/guardian/caregiver of the patient (under 17 years old). By electronically signing below, I consent to the patient receiving the Moderna or Pfizer vaccine I have chosen.Please type your full name, to serve as your electronic signature.(Required) CAPTCHA
