Covid 19 Vaccine Registration – The Premier Medical Clinic

Covid 10 Vaccine Registration Form

Do you qualify to receive the COVID-19 Vaccine as per FL State Mandate and Guidance for Phase 1a and Phase 1b vaccination?

Yes/No?

Select an appointment date/time

(Date/Time)

Vaccine Recipient Name *

First

Last

Date of Birth

Vaccine Recipient Physical Address

Gender at birth

Race

Ethnicity

Vaccine Recipient Phone Number

Mother's Maiden Name

Emergency Contact Name

Relationship to Emergency Contact

Phone Number of Emergency Contact

Email *

1. Are you feeling sick today?

Yes/No?

2. Have you ever received a dose of COVID-19 Vaccine?

Yes/No?

3a. Have you ever had an allergic reaction to a component of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures?

Yes/No?

3b. Have you ever had an allergic reaction to Polysorbate?

Yes/No?

3c. Have you ever had an allergic reaction to a previous dose of COVID-19 Vaccine?

Yes/No?

4. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?

Yes/No?

5. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a component of COVID-19 vaccine, polysorbate, or any vaccine or injectable medication? This would include food, pet, environmental, or oral medication allergies.

Yes/No?

6. Have you received any vaccine in the last 14 days?

Yes/No?

7. Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19?

Yes/No?

8. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? [note: monoclonal antibodies does not include antibiotics that you would be prescribed and filled at a pharmacy]

Yes/No?

9. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?

Yes/No?

10. Do you have a bleeding disorder or are you taking a blood thinner?

Yes/No?

11. Are you pregnant or breastfeeding?

Yes/No?

Which arm would you like to get the injection on (Left/Right)

Consent (check each box below after reading and prior to signing the form) *

I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet (the J&J Janssen Fact Sheet is available on https://www.fda.gov/media/146305/download), a copy of which I was provided with this Consent Form. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent Form.
I understand that at this time, the COVID-19 vaccine requires 2 doses given 21-28 days apart depending on the manufacturer. If this is my second dose, I will bring my vaccine card with me to be completed.
I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.
I understand that I will be receiving the vaccination at no cost to me.

4350 North Atlantic Avenue,

Monday-Friday: 8am to 6pm

321-613-5352

Covid 10 Vaccine Registration Form

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