MODERNA VACCINE SCREENER
MODERNA COVID-19
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FIRST NAME *
LAST NAME *
DATE OF BIRTH *
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DD
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YYYY
GENDER *
STREET ADDRESS *
CITY *
STATE *
ZIP CODE *
PHONE NUMBER *
INSURANCE PROVIDER
MEMBER ID
RX BIN
RX PCN
GROUP ID
WHAT IS THE RELATIONSHIP TO INSURANCE CARDHOLDER
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Are you sick today? (For example: a cold, fever or acute illness) *
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 EpiPen®, or for which you had to go to the hospital? If yes, what are you allergic to?
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Have you ever had a severe allergic reaction after receiving a COVID-19 vaccine? *
Have you ever had a severe allergic reaction after receiving another vaccine or injectable medication? *
Have you ever had a severe allergic reaction after receiving Polyethylene Glycol? *
Have you received monoclonal antibodies or convalescent plasma as part of a COVID-19 treatment in the past 90 days? *
Are you currently pregnant or breastfeeding? *
Do you have a bleeding disorder or are you taking a blood thinner? *
Do you have a weakened immune system or currently take medications that can diminish your immune response (i.e. HIV medications, steroids, anticancer drugs, or radiation treatment, etc?) *
Do you have a history of an immune-mediated syndrome characterized by thrombosis (abnormal blood clots) and thrombocytopenia (low platelets), such as heparin- induced thrombocytopenia (HIT)? *
Are you moderately/severely immunocompromised from a medical condition/immunosuppressive therapy, including/not limited to: active treatment for solid tumor/hematologic malignancy, solid organ/stem-cell transplant, primary immunodeficiency syndrome, advanced/untreated HIV infection, or active treatment with high dose corticosteroids/other immunosuppressive biologic agents? *
Do you have a history of Guillain-Barré syndrome (GBS)? *
Patient Race *
Patient Ethnicity *
MODERNA VACCINE DOSE SERIES REQUESTED *
INJECTION ROUTE *
PREFERRED INJECTION SITE *
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