DO NOT ADMINISTER VACCINE!
 
 
 
Thank you for submitting your vaccination form. Unfortunately, your answers indicate that you are unable to receive the vaccine that is currently available. Please contact your healthcare provider or your local health department for additional information.
Demographic Information
 First Name: Telephone:
 Last Name: DOB:
 Address: Age:
 Address2: Sex:
 City, St Zip: Email:
 Race: Ethnicity:
Health History Information
1. Is this person experiencing moderate to severe illness and/or a fever?
2. Has this person already received the COVID Vaccine?
2a. Which vaccine did you received?
2b. Date Received Vaccine?
3. Has this person had a severe allergic reaction (e.g., anaphylaxis) to any component of the vaccine for either Pfizer-BioNTech or Moderna COVID-19 vaccines?
4. Has this person received any type of vaccine within the past 14 days?
5. Has this person received passive antibody therapy (monoclonal antibodies or convalescent plasma) as part of COVID-19 treatment within the past 90 days?
6. Is this person Pregnant?
7. Is this person currently breastfeeding?
 
Client Signature:_____________________________________Date Signed:________________