COVID-19 Vaccine Administration Record
| Do you have allergies to latex, food, medications, or vaccine components? (such as eggs, thimerosal, gelatin, neomycin, phenol, or bovine protein)? | No |
|---|---|
| Did you ever experience any serious reaction after getting a vaccine? | No |
| In the past year, did you receive a transfusion of blood or blood products, or get injected immune (gamma) globulin or any antiviral drug? | No |
| Did you have any brain or other nervous system problems? | Don't know |
| Have you get vaccinated in the last 4 weeks? | No |
| Are your pregnant or planning to get pregnant or your partner is planning to get pregnant? | No |
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.
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.
Vaccine Name:
Manufacturer:
Route:
Site:
Dose:
Exp. Date:
Date of EUA:
Lot:
Date & Time of Vaccination:
Name of Vaccine Administrator:
Signature of Vaccine Administrator:
Keep a complete record of your patients’ coronavirus vaccinations with this free COVID-19 Vaccine Administration Record PDF Template! By linking this PDF template to an online form, you can quickly enter patient details and have it populate into your PDF template automatically — ready to download, print, and store in your medical practice’s records as polished, professional PDF documents. Jotform helps keeping PDFs and form data protected with GDPR compliance features, CCPA compliance features, and optional HIPAA features.
Need to customize the look of this COVID-19 Vaccine Administration Record Template? Use our drag-and-drop PDF Editor to add your logo, change fonts and colors, rearrange the layout of the page, and more. You can also customize your attached form, as well as the spreadsheet you use to track your PDF records in Jotform Tables! Stop using pen and paper to track patient vaccinations and do it more efficiently online with a free COVID-19 Vaccine Administration Record.
Child Medical History Template
This child medical history PDF template makes checking patients vitals and recording that important data easy. Add your own branding, adjust fields for your specific needs and then simply print out your PDF for the patient's file.
Veterinary Hospital Treatment Sheet Template
Veterinary Hospital Treatment Sheet helps both the hospital and pet owners in understanding and tracking a pet's treatment process. Just like any other hospitals, keeping patient's treatment records is necessary to monitor progress and make sure proper treatment is given. Having a veterinary treatment sheet also helps in planning and evaluating other treatments for the pet, facilitating research and creating a record for the pet's future care. If you are trying to create a treatment sheet and looking for a sample template, then look no further because Jotform offers a Veterinary Hospital Treatment Sheet template you can download, save, edit and print. This Veterinary Treatment Sheet template contains the necessary information for recording and tracking treatment process for your client's pet. It has information such as name of client, date and time, address, contact number, treatment performed, doctor's name, monitoring progress report and many more. This template is editable and allows you to add more information or remove if you need to. Add your hospital's logo or insert images to make it more personalized.
Professional Medical History Template
Medical History Record PDF template is here to help you in order to know the patient's case and previous condition. You can collect data about the patient and medical background with this Medical History Record PDF sample.
Simple Medical History Template
Once you have collected these medical data, you can record them as a pdf by using this medical history PDF template. In addition, you don't need to be worried about the safety of data.
First Aid Incident Report Template
Incidents must be reported and recorded to be sure that correct actions and treatment are made which should trigger management awareness and an investigation. The First-Aid Incident Report template contains injured person's personal details and contact details, the details and visible symptoms of injury, the Glasgow Coma Scale which is a neurological scale that expects to give a dependable and target method for chronicle the condition of an individual's awareness and brief information of treatment. Also, it contains the profile of the first-aider and signature of the person who prepares the report.
Personal Medical History Template
Medical History Record PDF template allows you to collect patients' data such as personal information, family history, and habits like, and symptoms. You can pick your patients with this medical history record sample.
These templates are suggested forms only. If you're using a form as a contract, or to gather personal (or personal health) info, or for some other purpose with legal implications, we recommend that you do your homework to ensure you are complying with applicable laws and that you consult an attorney before relying on any particular form.