Emergency Contact Name Please enter name* Relationship Please enter relationship* Phone number Enter Phone number*
If you answer Yes for question 5, Please specify
Date of last dose
Last COVID vaccine dose
10. 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 previous dose of EVUSHELD?
* A component of EVUSHELD, including polysorbate
* Any other vaccine or injectable medication?
* Something other than a component of EVUSHELD, polysorbate, or any vaccine or injectable medication? (This would include food, pet, environment, or oral medication allergies)
Please enter the information that apply to you only and enter N/A for other required fields