Elko Senior Center Registration and Consent February 19th, 2021

Nevada Health Centers, Inc.

COVID-19 VACCINE ADMINISTRATION RECORD & INFORMED CONSENT
Appointment *
Patient's Name *

First Name Middle Name Last Name
Date of Birth *

Month Day Year
Age *
Physical Address *

Street Address

Street Address Line 2

City State Initials

Postal / Zip Code
Phone Number *
Email
example@example.com
Gender

Female Male Transgender: Female to Male Transgender: Male to Female
Language most comfortable speaking
Do you need an interpreter?

Yes No
Hearing impaired or need sign language interpreter service?

Yes No
Race (Check all that apply) *

African American/Black Native Hawaiian/Pacific Islander Asian Caucasian/White (inc Hispanic) American Indian/Alaska Native Other Prefer not to answer
Ethnicity *

Non-Hispanic Hispanic/Latino Prefer not to answer
Emergency Contact Name *
Relationship to Emergency Contact *
Phone Number of Emergency Contact *

COVID-19 Vaccine Screen Questions

Yes

1. Are you feeling sick today?

2. Have you ever received a dose of COVID-19 Vaccine?

3a. Have you ever had an allergic reaction (e.g., anaphylaxis) to something? For example, a reaction for which you were treated with epinephrine or EpiPen or that you had to go to the hospital?

3b. Was the severe allergic reaction after receiving a COVID-19 vaccine?

3c.Was the severe allergic reaction after receiving another vaccine injectable medication?

4. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?

5. Have you received any vaccine in the last 14 days?

6. Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19?

7. Have a weakened immune system caused by something such as HIV infection or cancer or take immunosuppressive drugs or therapies?

8. Do you have a bleeding disorder or are you taking a blood thinner?

11. FOR FEMALES 9 years old or older: Are you pregnant or breastfeeding?

Informed Consent: I answered all the questions correctly to the best of my knowledge. I have read or have had explained to me the information contained in the EUA Fact Sheet or VIS about COVID-19 disease/vaccine. I have had a chance to ask question which were answered to my satisfaction. I understand the benefits and risks of the vaccine and request this vaccine be given to me or to the person named above for whom I am authorized to make this request. I answered all the questions correctly to the best of my knowledge.

I ACKNOWLEDGE THAT A COPY OF THE "NOTICE OF PRIVACY PRACTICE" HAS BEEN MADE AVAILABLE TO ME.
SIGN HERE

Clear
Date Signed

Month Day Year
Date
Should be Empty:

Nevada Health Centers, Inc.