HealthRx COVID-19 Vaccine Screening Form Logo
  • COVID-19 Vaccine Consent Form

    In order to receive the vaccine, you must be in the most appropriate phase of the vaccine rollout. Visit this link (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations.html) for more information at the federal level. States may have a different approach.
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  • How old will the person be on the day of vaccination?   *   

  • How may doses of COVID-19 vaccine were previously administered?      

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