Emergency Contact Name Please enter name* Relationship Please enter relationship* Phone number Enter Phone number*
If you answer Yes for question 5, Please specify Vaccine Type Pfizer Moderna J&J Date of last dose Last COVID vaccine dose First Dose Second Dose Booster Additional 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? Please Select Yes No * A component of EVUSHELD, including polysorbate Please Select Yes No * Any other vaccine or injectable medication? Please Select Yes No * 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 Select Yes No *
Please enter the information that apply to you only and enter N/A for other required fields