COVID-19 Vaccine Registration Form

Collects the personal details, insurance information, and health history needed to schedule a COVID-19 vaccine appointment.

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Page 1

Name

First Name

Last Name

National ID Number

Birth Date

Gender

Female Male Prefer not to say

Phone Number

Address

Street Address

City

State / Province

ZIP / Postal Code

Insurance Company

Insurance ID

Do you have any chronic health condition?

Please check the symptoms that apply

Fever Cough Fatigue Loss of taste or smell Shortness of breath Sore throat

Have you been diagnosed with COVID-19?

Yes No

If yes, please provide further details (date of diagnosis, whether you were hospitalized, treatment, etc.)

I declare that all the information provided is accurate.

I agree I disagree

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