COVID-19 Vaccine Preregistration

Patient Information

First Name Middle Initial Last Name

Date of Birth

Day

Month

Year

Are you a minor less than 18 years old?
Sex
Race
Hispanic Ethnicity
Do you have a disability?

Address

Street Address Line 1 Street Address Line 2 City State Zip County Cell/Primary Phone Home/Secondary Phone Number Email Would you like a reminder for the next appointment?
Insurance

Health Information

Are you feeling sick today?
Have you ever received a dose of COVID-19 vaccine?
If yes, which vaccine product did you receive?

If yes, what date did your receive the vaccine dose?

Day

Month

Year

In the past 14 days have you had contact with a confirmed COVID-19 patient?
Have you ever had an allergic reaction to:
(This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.)

Polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures
Polysorbate, which is found in some vaccines, film coated tablets, and intravenous steroids
A previous dose of COVID-19 vaccine
A vaccine or injectable therapy that contains multiple components, one of which is a COVID-19 vaccine component, but it is not known which component elicited the immediate reaction

Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a component of COVID-19 vaccine, or any vaccine or injectable medication? This would include food, pet, venom, environmental, or oral medication allergies.
Have you ever had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?
Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?
Do you have a bleeding disorder or are you taking a blood thinner?
Have you been diagnosed with an immune mediated syndrome characterized by thrombosis and thrombocytopenia or Heparin Induced Thrombocytopenia (HIT)?
Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
Do you have dermal fillers?
Are you pregnant or breastfeeding?
Do you have or have a history of Multisystem Inflammatory Syndrome in Children or Adults (MIS-C or MIS-A)?
Minor Selection Options (Documentation Required Unless Parent/Guardian Present)
Do you consent to the disclosure of the health and personal information you provide in Vaccine Navigator to local public health agencies and/or health care providers for the purpose of scheduling vaccination?