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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest 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
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