COVID-19 Vaccine Registration Form
Name
*
First Name
Last Name
Social Security Number (If none, use Driver’s License or State ID)
*
Birth Date
*
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Month
-
Day
Year
Date
Gender
*
Female
Male
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Health and Medical History
Do you have any chronic health condition?
*
Please indicate all health issues that are considered within the risk group. If none, list N/A.
Please list your current medication, if none list N/A
Please list down your allergies, if none list N/A
Please check the symptoms that apply
None
Loss of taste or smell
Body aches
Runny nose
Diarrhea
Cough
Difficulty in breathing
Persistant pain or pressure on chest
Nasal congestion
Sore throat
High fever
Other
Have you been diagnosed with COVID-19?
*
Yes
No
If yes, please provide further details (date of diagnition, were you hospitalized or not, treatment, etc.)
Is this for your first, second, or third vaccine? Or do you need a booster? If second or booster, select the vaccine you initially received.
*
First
Second- Moderna
Second- Pfizer
Pfizer- Third
Booster-Moderna
Booster-Pfizer
I hereby declare that all the given information are accurate.
*
Choose the date of your requested appointment. This appointment is not guaranteed until you receive confirmation.
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Month
-
Day
Year
Date
Signature
Please verify that you are human
*
Register
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