COVID-19 Vaccine Administration Record

Personal Information

margaret@example.com

Name

Margaret Robertson

Phone Number

(230) 420-3042

Address

1171 Village View Drive

Washington, Maryland, 21202

Medical History

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

Do you have any of the followings?

Cold

Fever

Do you have any of the followings? (select all that apply)

Asthma

Do you have immunocompromised condition? (select all that apply)

None

In the last 14 days, have you travelled internationally?

In the last 14 days, have you contacted with a person who was confirmed to have COVID-19?

Have you ever tested positive for COVID-19?

Emergency Contact Information

Name

Mike Robertson

Phone Number

(203) 029-4023

Relation

Cousin

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Consent

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.

Date

02/24/2021

Signature