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11/4/2022 Flu & COVID Booster Vaccination Event
19
Questions
START
HIPAA
Compliance
1
Name
*
This field is required.
First Name
Last Name
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2
Are you a current patient at Texas Native Health (Formerly Urban Inter-Tribal Center of Texas). **This event is only for current patients**
*
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YES
NO
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3
Date of Birth
*
This field is required.
-
Date
Month
Day
Year
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4
Age
*
This field is required.
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5
Gender (At Birth)
*
This field is required.
Female
Male
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6
Phone Number
*
This field is required.
Area Code
Phone Number
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7
Vaccine(s) to receive?
*
This field is required.
If you are receiving a COVID 19 shot, please bring your Vaccination Card from previous COVID 19 vaccinations.
Influenza ( ages 3 -64)
Influenza ( ages 65 & older)
COVID-19 - Moderna ( ages 18 & older)
COVID-19 Pfizer ( ages 12 & older)
Other
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8
Appointment
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9
Primary Care Provider (PCP) Name
*
This field is required.
First Name
Last Name
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10
PCP Phone Number
*
This field is required.
Area Code
Phone Number
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11
Do you have any allergies to medications, food, latex, or a vaccine component?
*
This field is required.
YES
NO
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12
Have you ever had a serious reaction after receiving a vaccination?
*
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YES
NO
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13
Do you have a long-term health condition related to heart disease, lung disease, asthma, kidney disease, metabolic disease (diabetes), anemia, or other blood disorders?
*
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YES
NO
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14
Do you have cancer, leukemia, HIV/AIDS, or any other immunological disorder?
*
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YES
NO
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15
Have you received a COVID 19 Vaccine on or after September 4, 2022?
*
This field is required.
If yes, you will not be eligible to receive a COVID 19 vaccination.
YES
NO
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16
Have you been diagnosed or tested positive for COVID 19 on or after August 4, 2022?
If yes, you will not be eligible to receive a COVID 19 vaccination.
YES
NO
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17
Was this form completed by someone OTHER THAN the patient?
*
This field is required.
YES
NO
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18
Form completed by:
*
This field is required.
First Name
Last Name
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19
Signature
*
This field is required.
By signing you agree to the Consent to Vaccination.
Clear
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