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Covid Vaccine Registration Form
Completion of this form is required before scheduling an appointment with Madeleine C Weiser MD, PC
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* Indicates required question
Email
*
Your email
Patient First Name
*
Your answer
Patient Last Name
*
Your answer
Patient Date of Birth
*
MM
/
DD
/
YYYY
Patient Gender assigned at birth
*
Choose
Female
Male
Race (required for state reporting)
*
Choose
Alaskan Native
American Indian
Asian
Black
Native Hawaiian
Pacific Islander
White
Other
Prefer not to answer
Ethnicity (required for state reporting)
*
Choose
Hispanic/Latino
Not Hispanic/Latino
Prefer not to answer
Insurance Company Name
*
Choose
Aetna
Aetna Better Health (Medicaid)
Blue Cross/Blue Shield
Cigna
HealthPartners (Medicaid)
Independence Blue Cross
Keystone First (Medicaid)
Keystone Health Plan East (IBC)
Medicare
Meritain
No Insurance
Oxford
Personal Choice (IBC)
United Healthcare
Other
Insurance ID Number (if no insurance type 0)
*
Your answer
Full Name of Subscriber for Insurance (if different from the patient)
Your answer
Date of Birth of Subscriber (if different from the patient)
MM
/
DD
/
YYYY
Patient's Primary Care Doctor (if part of a Nemours practice, please type Nemours)
Your answer
Mobile Phone Number
*
Your answer
Street Address (example: 123 Apple Way)
*
Your answer
City, State, Zip (example: Ardmore, PA 19003)
*
Your answer
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?
*
Yes
No
I don't know
Do you carry an Epipen? (If yes, please bring it with you and inform the office at check in. You will need to wait 30 minutes after your vaccine instead of 15 minutes.)
*
Yes
No
Have you received passive anitbody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? IF YES, YOU NEED TO WAIT 90 DAYS FROM THAT TREATMENT TO RECEIVE YOUR VACCINE.
*
Yes (You need to wait 90 days from that treatment to receive your vaccine)
No
I don't know
Have you been hospitalized for COVID-19 in the last 30 days?
*
Yes (YOU SHOULD NOT RECEIVE THE VACCINE AT THIS TIME.)
No
Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppresive drugs or therapies?
*
Yes
No
Do you have a bleeding disorder or are you taking a blood thinner?
*
Yes
No
Are you pregnant or is there a chance you could become pregnant during the next month?
*
Yes
No
Maybe
Have you had a seizure or a brain or other nervous system problem or ever had Guillan-Barre Syndrome
*
Seizure
Brain/other nervous system problem
Guillan-Barre Syndrome
None of the above
Other:
Required
Have you already received an initial dose of the COVID-19 vaccine?
*
Yes (You MUST bring proof of your first vaccine with you. We only have the Pfizer vaccine available)
No
Have you received any other vaccines in the last 14 days?
*
Yes
No
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) (
www.cdc.gov/vaccines/covid-19/eua/index.html
), a copy of which I was provided with this Consent and Release. I request the vaccine to be given to me/my child. I consent to, or give consent for, the administration of the vaccine(s) and the notification to the PA Department of Health that this vaccine was given. I fully release and discharge Madeleine C Weiser MD, PC (owner and employees) from any liability for illness, injury, loss or damage which may result there from. I authorize the release of any medical or other information necessary to process this claim. I understand that I should remain in the instructed location for 15 minutes for observation in case there is an adverse reaction.
*
Choose
I understand and am filling this request for myself.
I understand and am filling this request for a MINOR.
Name of person completing this form
*
Your answer
A copy of your responses will be emailed to the address you provided.
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