COVID-19 Vaccination Request Form

This form lets patients request a COVID-19 vaccination appointment while collecting relevant medical information to assess their eligibility.

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Name

First Name

Last Name

Phone Number

Are you pregnant, breastfeeding, or have plans to be pregnant in the next three months?

Yes No

Have you undergone any X-ray treatment in the past 3 months?

Yes No

Are you currently under medication?

Yes No

Do you have allergies or hypersensitivity to eggs, any known vaccine, or drugs, insects, seafood, etc.?

Yes No

Please provide details regarding your allergies or hypersensitivity

I confirm that I do not have or not experiencing:

Fever COVID-19 symptoms Another vaccine within the past two weeks None of the above

I declare that:

The information I provided is true and accurate I have not been diagnosed with active COVID-19 I understand the risks and benefits of vaccination

I consent to receive the COVID-19 vaccine

Name of Patient

First Name

Last Name

Signature

Sign here

Date

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