Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something? For example, a reaction for which you were treated with epinephrine or Epi Pen or for which you had to go to the hospital? Including: Polysorbate? *
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Yes
No
Unknown
Have you ever had a serious reaction after any vaccination of injectable medication including a previous dose of the COVID-19 vaccine? *
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Yes
No
Unknown
In the past 14 days have you had contact with a confirmed COVID-19 patient? *
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Yes
No
Unknown
Are you breastfeeding or pregnant? If you are, an order from your physician is required. *
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Yes
No
Unknown
Have you received passive antibody therapy as a treatment for COVID-19? If you have, it is required that you wait 90 days after your infusion for a vaccine. *
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Yes
No
Maybe
Unknown
Are you immunocompromised? (taking medication or being treated for cancer, leukemia, HIV/AIDS or other immune system problems or taking medication that affects your immune system). *
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Yes
No
Unknown
Do you have a bleeding disorder or are you taking a blood thinner? *
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Yes
No
Unknown
Once form is completed and submitted, it will be reviewed. After review you will receive an email with your appointment date and time. Please understand that this form is monitored by one nurse and is not checked multiple times a day. *