COVID-19 Vaccination Accept/Decline Form

This form lets an individual formally record whether they accept or decline the COVID-19 vaccine, including their reason if they decline.

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Patient Information

Name

First Name

Last Name

Age

Gender

Male Female Other

Date of Birth

Email

Phone Number

Address

Street Address

City

State / Province

ZIP / Postal Code

Do you accept or decline receiving the COVID-19 vaccination?

Accept Decline

What is the reason why you're refusing to be vaccinated against COVID-19?

I certify that the information provided above is accurate

Signature

Sign here

Date Signed

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