This voucher permits the individual named below to receive Covid-19 vaccine.
BRING THIS VOUCHER WITH YOU
 
Dispense Assist
Covid-19 Vaccine Voucher
 
Vaccine:
 
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?
 
I, the undersigned, certify that all of the above information is correct to the best of my knowledge. I hereby authorize the recipient of this document to share this information with public health entities at the local, state and federal level for purposes of ensuring medication efficacy and safety.  I have been offered a copy of Privacy Practices.
Client Signature:_____________________________________Date Signed:________________
 
Clinician Use Only:
Vaccine Provided:  IM  Nasal  ID
 
 Place Lot # Sticker Here Location: (R) (L) (Deltoid) (VL)
 
Clinic Site:____________________________________
 
 
Vaccinator's Signature:______________________    Date:_____________
 
Fact sheet: Vaccine Information Statements