Independent RX LTC - COVID-19 Vaccine Registration Form

Name*

FIRST NAMEMIDDLE INITIALLAST NAME

DATE OF BIRTH*

Date

AGE*

17 OR UNDER?*

YesNo

Race*

Ethnicity*

Sex*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

COUNTY OF RESIDENCE*

Phone Number*

Please enter a valid phone number.

Okay to text?

EMAIL

example@example.com

Okay to email?

Have you had any type of vaccine in the last two weeks?*

YesNo

Have you ever had a severe allergic reaction to a vaccine or any injection in the past?*

YesNo

Have you ever tested positive for COVID-19 or had a doctor tell you that you had COVID-19?*

YesNo

Have you been identified as either a probable or confirmed case of COVID-19 in the last two weeks?*

YesNo

Have you received antibody therapy (monoclonal or convalescent plasma) for COVID-19 in the last 3 months?*

YesNo

Do you have any serious health conditions (often called co-morbidities)?*

YesNo

Do you have a weakened immune system (ie, from HIV or cancer) or are you on immunosuppressive drugs?*

YesNo

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

YesNo

Are you pregnant or breastfeeding?*

YesNo

Do you feel sick today?*

YesNo

Is this your first, second or third dose in the last month?*

First doseSecond doseThird Dose

First dose manufacturer (if applicable)

Pfizer, Johnson & Johnson, Moderna

First dose date (if applicable)

Date

Second dose manufacturer (if applicable)

Pfizer, Johnson & Johnson, Moderna

Second dose date (if applicable)

Date

What group are you in?*

Assisted Living Facility ResidentAssisted Living Facility StaffSkilled Nursing Facility ResidentSkilled Nursing Facility Staff

Facility Name*

Type the name of your facility

Please visit the CDC website cdc.gov/coronavirus/2019-ncov/vaccines/index.html to learn about the benefits and risks (VIS) of the COVID-19 vaccine. Please visit our website (posted at the clinic) to read our Privacy Policy (PP). By signing below, you agree that

1) you reviewed both the VIS and PP,
2) you understand the benefits and risks of the vaccine and you are asking that the vaccine be given to you or the person named on this form for whom you are authorized to make this request,
3) you hereby consent that we can bill your insurance, if applicable,
4) you authorize the release of this vaccination record and all information on this form to your state’s Immunization Program and the CDC, and
5) we can release this record to your doctor, school, or employer if requested.

If the person who is being vaccinated is age 17 or under, by signing below you agree that you are authorized to consent to the vaccination of the patient and the patient on this form may receive vaccine with or without you, as the parent or guardian, present at the time of vaccination. After receiving your vaccine we recommend you wait at least 15 minutes.

If you leave the vaccination site before 15 minutes has passed after your vaccination you assume any risks associated with not waiting the recommended amount of time. Please be aware that staff may be taking pictures for social media and clinic improvement purposes. If you do not want your picture to be taken please let us know at the clinic.

PATIENT CONSENT/SIGNATURE (or parent/guardian if patient is age 17 or under)*

DATE OF CONSENT*

Date

COVID-19 Vaccine Registration Form

PATIENT QUESTIONS - ANSWER THE DAY OF VACCINATION