Henry/Stark County COVID Vaccine Registration
You MUST Bring Government Issued ID. No Insurance Cards are Necessary. There is No Cost. You Must Pre-Register by Completing and Submitting this Form.
18 Years and Older - MODERNA
First & Second Dose Appointments
JUNE 25, 2021 Arrive Anytime Between: 1:00 PM - 5:00 PM
Henry/Stark County Health Dept. | 110 N. Burr BLVD. Kewanee, IL 61443
Name (Last, First)
Street Address Line 2
State / Province
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Hispanic or Latino
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Race (select all that apply)
American Indian or Alaska Native
Black or African American
Native Hawaiian or Other Pacific Islander
Date of Birth
Age (MUST Be 18 years & older)
Please enter a valid phone number.
This appointment will be for the MODERNA Vaccine. If you Previously Received the PFIZER or Johnson and Johnson (Janssen) Vaccine; Please STOP and Cancel this Registration and Call (883) 621-1284 for additional Options.
I Certify That I Have Never Received a PFIZER or JOHNSON & JOHNSON COVID-19 Vaccine
Is This Your FIRST or SECOND Dose of the Moderna Vaccine?
This is my FIRST Dose
This is my SECOND Dose
If This is Your SECOND Dose, On What Date Did You Receive Your FIRST Dose? (FIRST Dose Appointments, Leave Blank)
Are you Pregnant or Breastfeeding?
Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something?
For example, a reaction for which you were treated with epinephrine or EpiPen®, or for which you had to go to the hospital?
Have you had a severe allergic reaction after receiving a COVID-19 vaccine?
Have you had a
severe allergic reaction after receiving another vaccine or another injectable medication?
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 explain it.
Are you feeling sick today?
Have you had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?
Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?
Have you received another vaccine in the last 14 days, including a Flu Shot?
Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
Do you have a bleeding disorder or are you taking a blood thinner?
You are being offered the Moderna COVID-19 Vaccine to prevent Coronavirus Disease 2019 (COVID-19) caused by SARS-CoV-2. This Fact Sheet contains information to help you understand the risks and benefits of the Moderna COVID-19 Vaccine, which you may receive because there is currently a pandemic of COVID-19.
Please Print and/or Save a Copy of the Emergency Use Authorization (EUA) Disclosure Below.
I Certify That I Have Read and Printed/Saved the EUA Document. I Further Certify that if I Need an Additional Copy, I Will Obtain Duplicates by Visiting www.modernatx.com/covid19vaccine-eua.
I Consent to Receiving the EUA Electronically.
By signing below, I confirm that I have been provided the Emergency Use Authorization information and Vaccine Information Statement for COVID vaccine and have had an opportunity to ask questions that were answered to my satisfaction. I understand the benefits and the risks of the vaccine and request the vaccine be given to me or to the person for whom I am authorized to make this request. I understand the information will be documented in the I-CARE Registry; Illinois Comprehensive Automated Immunization Registry exchange. By "clicking submit" using any device, means or action, you consent to using an electronic signature. You further agree that your signature on this document is as valid as if you signed the document in writing.
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