COVID-19 Vaccine Prescreening
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Name *
Driver's License Number *
Street Address *
City *
State *
Zip Code *
Email *
Phone Number *
Date of Birth *
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Sex *
Ethnicity *
Race *
Mother's Maiden Name *
Allergies *
Primary Physician *
Medicare Number (Part B) *
Do you have insurance other than Medicare? *
If so, list the Insurance Carrier and ID
Are you sick today (fever/cough/diarrhea/vomiting)? *
Have you ever received a dose of COVID-19 vaccine? *
If yes, which vaccine product did you receive?
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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? *
Have you ever had an allergic reaction to Polysorbate? *
Have you ever had an allergic reaction to a previous dose of COVID-19 vaccine? *
Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication? *
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. *
Have you ever had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19? *
Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? *
Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? *
Do you have a bleeding disorder or are you taking a blood thinner? *
Have you ever fainted or felt dizzy after receiving a vaccine? *
Have you ever had a reaction after receiving a vaccine? *
Do you have a long term health problem with heart disease, lung diseasee, asthma. kidney disease, neurologic or neuromuscular disease, liver, metabolic disease ( Diabetes), or anemia or another blood disorder? *
Do you have a weakened immune system because of HIV/ AIDS or another disease that affects the immune system, long term treatment with drugs such as high-dose steroids, or cancer treatment with radiation or drugs? *
Do you have allergies to latex, medications, food or vaccines? (Examples: eggs, bovine protein, gelatin, gentamicin, polymyxin, neomycin, phenol. yeast or thimerosal). *
Have you ever had a seizure disorder for which you are on seizure medications, a brain disorder Guillain Barre syndrome or other nervous system problems? *
For women: are you pregnant or breastfeeding, or considering becoming pregnant in the next month? *
Are you currently on home infusions or weekly injections, high-dose methotreate, azathrimprine or 6 mercaptopurine, antivirals, anticancer drugs or radiation treatments? *
Have you received any vaccinations or skin tests in the past four weeks? *
Have you received a transfusion of blood blood products or been given a medication called immune (gamma) globulin in the last year? *
Are you currently taking high-dose steroid therapy (prednisone >20mg/day or equivalent) for longer than two weeks? *
Is the person being vaccinated over the age of 18? *
I have read, or have had read to me, the written information regarding the vaccine(s) being administered. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s) being administered and have received a copy of a current Vaccine Information Sheet. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Pharmville Drug, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s). I certify that I am at least 18 years old and hereby give my consent to the pharmacists of Pharmville Drug to administer the vaccine(s). If under 18 years old signature by parent or guardian is required. I agree to wait near the vaccination location for approximately 15 minutes for observation by the pharmacist. *
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