• Prevacccination Checklist

    for COVID-19 Vaccines
  • For vaccine recipients: The following questions will help us determine if there is any reason you should not get the COVID-19 vaccine today. If you answer "yes" to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions may be asked. If a question is not clear, please ask your healthcare provider to explainit.

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  • 3. 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

    A component of a COVID-19 vaccine including either of the following:

     

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  • After completing form, please click Preview + Save PDF to save a copy of the form onto your desktop for uploading below and on the main registration page if you have not completed it fully.  Click Submit after the form uploadings have been completed.

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