COVID-19 Vaccine Form

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The COVID-19 vaccine will reduce the risk of being suffering from the new type of Coronavirus disease as known as COVID-19.

Please be aware that the vaccine is not completely effective like all other medicines. It can take a few weeks for your body to build up protection from the vaccine. There is always a chance to get infected by Coronavirus even with the vaccine; however, the vaccine lessens the severity of any infection. Two doses will reduce the chance of being seriously ill and reduce the risk of death due to Coronavirus.

You still need to follow the health instructions in your workplace and in public areas, such as wearing a mask and keeping the distance from others after you received the COVID-19 vaccine.

The vaccine has some side effects as the other vaccines/medicines, but not everyone gets them.

The most likely side effects that you may experience from the vaccine

Fever
Pain at the injection site
Redness and hardness of the skin at the injection site
Headache
Muscle aches or pain
Joint aches or pain
Fatigue (tiredness)
Nausea/vomiting
Chills
Underarm gland swelling on the side of study vaccination

If you think you are experiencing any side effects, please remain calm and see your doctor immediately.

If you are currently pregnant or planning to get pregnant or your partner is planning to get pregnant; please see your doctor before getting vaccinated.

Are you feeling sick today?* This field is required.

Yes

Don't Know

In the last 10 days, have you had a COVID-19 test because you had symptoms and are still awaiting your test results or been told by a health care provider or health department to isolate or quarantine at home due to COVID-19 infection or exposure?* This field is required.

Yes

Don't Know

Have you ever had an immediate allergic reaction (e.g., hives, facial swelling, difficulty breathing,anaphylaxis)to any vaccine, injection, or shot or to any component of the COVID-19 vaccine, or asevere allergic reaction (anaphylaxis) to anything?* This field is required.

Yes

Don't Know

Are you pregnant or considering becoming pregnant?* This field is required.

Yes

Don't Know

Do you have cancer, leukemia, HIV/AIDS or any other condition that weakens the immunesystem?* This field is required.

Yes

Don't Know

Do you take any medications that affect your immune system, such as cortisone, prednisone or other steroids, anticancer drugs, or have you had any radiation treatments?* This field is required.

Yes

Don't Know

Do you have a bleeding disorder, a history of blood clots or are you taking a blood thinner?* This field is required.

Yes

Don't Know

Do you have a history of myocarditis (inflammation of the heart muscle) or pericarditis(inflammation of the lining around the heart)?* This field is required.

Yes

Don't Know

If you had a previous dose of Janssen (Johnson & Johnson), did you develop thrombosis withthrombocytopenia syndrome (TTS)?* This field is required.

Yes

Don't Know

I didn't have a previous Dose of Janssen Vaccine

Have you received a previous dose of a non-FDA authorized or approved COVID-19 vaccineauthorized by the WHO1 but not by the FDA (AstraZeneca – VAXZEVRIA, Sinovac – CORONAVAC, Serum Institute of India – COVISHIELD, Sinopharm/BIBP, COVAXIN, Novavax – Covovax, Nuvaxovid)?* This field is required.

Yes

Don't Know

Have you been treated with antibody therapy or convalescent plasma for COVID-19 in the past 90 days (3 months)? If yes, when did you receive the last dose? If yes, what was the date?* This field is required.

Are you 12 years old or older, and have you received 2 doses of the Pfizer vaccine, the second dose being at least 5 months ago? If Yes, What is the Date of the second dose?* This field is required.

Have you received 2 doses of the Moderna vaccine, the second dose being at least 5 months ago? If Yes, what is the date of the 2nd Dose?* This field is required.

Have you received a previous dose of the Janssen vaccine, at least 2 months ago? If Yes, What is the date of that dose?* This field is required.

Do you have any of the followings? (select all that apply)* This field is required.

Lung disease

Heart disease

Asthma

Kidney Disease

Diabetes

Anemia

Blood disorder

None

Do you have immunocompromised condition? (select all that apply)* This field is required.

Cancer

Leukemia

Lymphoma

HIV/AIDS

Transplant

Asplenia

CSF leak

Cochlear implant

None

In the last 14 days, have you contacted with a person who was confirmed to have COVID-19?* This field is required.

Yes

Not sure

In the last 14 days, have you travelled internationally?* This field is required.

Yes

Do you have any of the followings?* This field is required.

Cough

Cold

Fever

Shortness of breath

Sore throat

Loss of smell/taste

Abdominal pain/diarrhea

Abnormal bruising or bleeding/eye redness

None

Name* This field is required.

First Name

Last Name

Date of Birth* This field is required.

example@example.com

Phone Number* This field is required.

Please enter a valid phone number.

Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Gender* This field is required.

Woman/Girl

Man/ Boy

Transgender Woman/Girl

Transgender Man/Boy

Non-Binary Person

Gender non conforming

Not Sure/ Questioning

Choose not to respond

Sex Assigned at Birth* This field is required.

Male

Female

Intersex

Choose not to respond

Marital Status* This field is required.

Single

Divorced

Married

Widow

Civil Union

Unknown

Legally Seperated

Life Partner

Preferred Language

Ethnicity* This field is required.

Declined

Hispanic Origin

Non-Hispanic Origin

Unknown

Race* This field is required.

Native American or Alaskan

Asian

African American or Black

Declined

Native Hawaiian or Pacific Islander

White

Which vaccine would you like to receive?* This field is required.

Pfizer

Moderna

Which dose would you like to receive?* This field is required.Please make sure you are eligible, according to CDC vaccine schedules, for your additional doses

First Dose

Second Dose

Booster

Second Booster ( For patients aged 50 and older or age 18-49 immunocompromised patient )

By signing this form,

I hereby accept that I have read and understood the acknowledgment letter provided above.

I declare that the information I have provided above is correct.

I am giving my full consent to get the COVID-19 vaccine of my own will.

Date* This field is required.

Date

COVID-19 Vaccine Form