COVID-19 vaccine registration

Please complete all sections of this form and sign. It is required to get your vaccination.

Name

First Name and Middle InitialLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Telephone

Area CodePhone Number

Email

example@example.com

Date of Birth

Date

Age

Gender on insurance card (required by insurance)

MaleFemale

Do you have health insurance?

YesNo

Health Insurance Company

Insurance Plan

Policy #

Group

Emergency Contact (required)

Emergency Phone

Are you currently sick or currently in an isolation or quarantine period for COVID-19?

YesNo

Have you received passive antibody therapy as treatment for COVID-19?

YesNo

Have you ever had a severe allergic reaction to something? (for example anaphylaxis or something you were treated with epinephrine or an EpiPen with)

YesNoIf yes please describe

Have you ever had a serious reaction after receiving a vaccine or injectable medication?

YesNoIf yes, please describe

Have you ever had endocarditis, pericarditis, Guillian Barre Syndrome, or had a dermal filler?

YesNo

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

YesNo

Do you currently have a weakened immune system, take immunosuppressive medications, or receive radiation or chemotherapy treatment?

YesNo

Are you pregnant or currently breastfeeding?

YesNo

Have you ever received a dose of COVID-19 vaccine?

YesNoIf yes, which vaccine and when?

I have been given a copy and have read, or have had explained to me, the information in the FACT SHEET for the COVID-19 vaccine. I understand the FDA has authorized emergency use of the COVID-19 vaccine, which is not an FDA-approved vaccine. I have had the chance to ask questions that were answered to my satisfaction.

I understand the COVID-19 vaccine requires one or more booster doses to be effective, I intend to receive doses in accordance with the vaccination schedule at the time.

My signature acknowledges that I was advised to remain on site for 15 minutes after receiving the vaccine. Those with a history of previous anaphylactic reactions, should stay on site for 30 minutes. I understand that if I experience any adverse reaction, it will be my responsibility to follow up with my primary care physician.

An administration fee may be billed to third party payers. I authorize Greenlake Primary Care to bill any and all third party payers for this service. I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits or payment of medical benefits either to myself or to the party who accepts assignment for services described herein.

I understand the significant known and potential risks and benefits of the COVID-19 vaccine as explained in the FACT SHEET and that some potential risks and benefits may remain unknown. I REQUEST THE COVID-19 VACCINE BE GIVEN TO ME OR THE PERSON LISTED ABOVE

Patient or Parent/Guardian Signature

Clear

Date

COVID Vaccine Registration