SECOND DOSE ONLY - Elko Convention Center Vaccination Clinic

NEVADA HEALTH CENTERS, Inc.

COVID-19 Vaccine Administration Record & Informed Consent
This registration is for receiving your SECOND dose of the COVID vaccine only. Select your appointment time: *
Last Name *
First Name *
Middle Name
Date of Birth: Month/Day/Year *
Age *
Address *
City *
State *
Zip Code *
Phone Number *
Email Address
example@example.com
Gender *

Female Male Transgender: Female to Male Transgender: Male to Female
Language most comfortable speaking
Hearing impaired or need sign language interpreter services?

Yes No
Race: Check all that apply *

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

Non-Hispanic Hispanic/Latino Prefer not to answer
Patient Emergency Contact: (For emergency only such as passing out or needing to be taken to a hospital)
Name *
Relationship *
Phone Number *
Please answer the questions below to help us determine if there is any reason you should not get the COVID-19 vaccine today. If you need help, please ask a staff person.
IS THE PERSON RECEIVING THE COVID 19 VACCINE:
1. Feeling sick today?

Yes No Don't Know
2. Ever received COVID Vaccine before? If yes, what product? *

Pfizer Moderna Other product Yes No Don't Know
3. Ever had a severe allergic reaction (e.g., anaphylaxis) to something? For example, a reaction for which you were treated with epinepherine or EpiPen* or that you had to go to the hospital? *

Yes No Don't Know
3a. Was the severe allergic reaction after receiving a COVID-19 vaccine?

Yes No Don't Know
3b. Was the severe allergic reaction after receiving another vaccine or injectable medication

Yes No Don't Know
4. Received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? *

Yes No Don't Know
5. Received any vaccine within the past 14 days? *

Yes No Don't Know
6. Ever had a positive test for COVID-19 or had a doctor ever told you that had COVID-19? *

Yes No Don't Know
7. Have a weakened immune system caused by something such as HIV infectionor cancer or take immunosuppressive drugs? *

Yes No Don't Know
8. Have a bleeding disorder or taking blood thinners? *

Yes No Don't Know
9. FOR FEMALES 9 years old or older: Are you pregnant or breastfeeding? *

Yes No Don't Know
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 questions 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

Month Day Year
Date
Personnel Groups: Please check the personnel group that best describes you.

Frontline Healthcare Personnel (Acute Care Hospital Setting) Healthcare Personnel in a Long Term Care Facility Frontline Healthcare Personnel (Psychiatric/Substance Abuse Hospital Setting) Emergency Medical Service Personnel (EMS) Frontline Public Health Personnel Laboratory Workers Pharmacist/Pharmacy Technicians Healthcare Personnel (Outpatient Setting, includes dentists, optometrists, etc.) Home Healthcare Personnel Nevada Department of Corrections Personnel/Juvenile Detention Center Staff Frontline Law Enforcement Personnel (includes Police Departments, Sheriff's Offices and NV Highway Patrol) Deployed and Mission Critical Personnel State Emergency Operations Center Personnel POD/SERV NV Volunteers Elementary and Secondary Education Personnel Childcare Personnel Higher Education Personnel Essential Public Transportation Personnel Agriculture and Food Processing Personnel Essential Retail Workforce (includes grocery, big box stores, gas stations, and truck stops) Logistics and Supply Chain Workforce (includes warehouse, storage and distribution, couriers, delivery, messengers, postal services, truck transportation, and wholesale traders) Utilities and Communications (includes water authorities, natural gas, internet, telephone, electric, news, radio, newspapers, waste collection and disposal) Nevada Department of Transportation Personnel/Local Road Work Personnel Community Support Personnel (includes food banks, Welfare, WIC, Department of Employment, Training and Rehabilitation, Division of Child and Family Services) Airport Operations Personnel Depository Credit Institution Workforce (includes commercial banks, credit unions, and armored car services) Mortuary Services Remaining Public Health Workforce (includes contact tracers, immunization and public health programs, regulatory authorities, etc.) Other Essential Personnel (includes justice courts, juvenile probation, alternative sentencing, etc.) Nevada Department of Corrections (NDOC) Inmates Age 55+ Age 18-64 with Chronic Health Conditions (Please Specify Below) Other Frontline Personnel (Please Specify Below)
Other Frontline Personnel
Chronic Health Condition
Should be Empty:

NEVADA HEALTH CENTERS, Inc.

IS THE PERSON RECEIVING THE COVID 19 VACCINE: