COVID Vaccination Registration Form Si usted necesita esta forma in EspaƱol, el idioma se puede escoger arriba a la derecha.Today's Date* MM slash DD slash YYYY Name* First Middle Last Gender* M F Mother's Maiden Name* Date of Birth* MM slash DD slash YYYY Age*Contact Number*Your Email Address* Home Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are you registering for your first dose or second dose?* First Second From what manufacturer was your first dose?* Moderna Pfizer Johnson & Johnson WARNINGWe do not offer vaccines from Pfizer. If your first dose was from Pfizer, please do not proceed.WARNINGIf your first dose was from Johnson & Johnson, you need not be vaccinated again. Please do not proceed.What is your race Caucasian Native American Asian Black Pacific Islander Ethnicity:H - Hispanic/Latino N - Not Hispanic/Latino H N Age 18+* I certify that I am 18 years of age or older.Have you ever had an allergic reaction to: (check all that apply)* 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 Polysorbate A previous dose of COVID-19 vaccine Any component of the Janssen COVID-19 Vaccine - The Janssen COVID-19 Vaccine includes the following ingredients: recombinant, replication-incompetent adenovirus type 26 expressing the SARS-CoV-2 spike protein, citric acid monohydrate, trisodium citrate dihydrate, ethanol, 2-hydroxypropyl-Ī²-cyclodextrin (HBCD), polysorbate-80, sodium chloride None of the above WarningYOU ARE NOT ELIGIBLE FOR THIS VACCINATIONIf you have had an allergic reaction to any vaccine or other injectable medication, you should talk to your personal physician to decide if it is safe before getting vaccinated.If you and your doctor decide to proceed with vaccination, we recommend scheduling your vaccination at a hospital-based vaccine clinic for increased safety and monitoring.Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?* Yes No WarningYOU ARE NOT ELIGIBLE FOR THIS VACCINATIONIf you have had an allergic reaction to any vaccine or other injectable medication, you should talk to your personal physician to decide if it is safe before getting vaccinated.If you and your doctor decide to proceed with vaccination, we recommend scheduling your vaccination at a hospital-based vaccine clinic for increased safety and monitoring.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 Please be aware:* You may still receive the vaccination.People with a history of severe allergies not related to vaccines or other injectable therapies may get vaccinated. For increased safety, you should be monitored for a longer period of time (approximately 30 min). If your allergic reactions are severe, consider scheduling your appointment at a hospital-based vaccine clinic for added safety. I have read the above warning and wish to be vaccinated against COVID19.Do you have a bleeding disorder or are you taking a blood thinner? Yes No Please be aware:*You may still receive the vaccination.Please be aware that you are at increased risk of bruising at the injection site.You should keep pressure over the injection area for at least 5 minutes to reduce the bruising.Please alert the person administering your vaccine of your condition. I have read the above warning and wish to be vaccinated against COVID19.Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?* Yes No Has it been 90+ days since your treatment? Yes No You may still receive the vaccinationYou may still receive the vaccination.WarningYOU ARE NOT ELIGIBLE FOR THIS VACCINATIONYou should wait at least 90 days before getting a COVID-19 vaccine.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 Please be aware:*You may still receive the vaccination.People with weakened immune systems might be at increased risk for severe COVID-19 and may receive a COVID-19 vaccine.However, you must be aware that there is limited safety data.There is also a potential for reduced immune responses to the vaccine. I have read the above warning and wish to be vaccinated against COVID19.Are you pregnant or breastfeeding?* Yes No Please be aware:*You may still receive the vaccination.People who are pregnant are at increased risk for severe illness from COVID-19 and may choose to be vaccinated.However, it is important for you to know that there is only limited data available on the safety of COVID-19 vaccines administered during pregnancy.Being vaccinated during pregnancy is a personal choice. There are not sufficient data on the safety of the COVID-19 vaccines in breastfeeding women nor on the effects of these vaccines on breastfed infants.Women who are breastfeeding may choose to be vaccinated but it is a personal choice. If you are pregnant or breastfeeding and have questions if you should receive the COVID-19 vaccine, please consult your personal physician. I have read the above warning and wish to be vaccinated against COVID19.Consent for Treatment and Privacy NoticeInformed Consent and Verification that must be read.*I certify that the information I have provided is true and accurate. I have had a chance to review the Covid-19 vaccine Information (EUA Fact Sheet) and consent to receive the vaccine. I have had a chance to ask questions, which were answered to my satisfaction. I believe I understand the benefits and risks of the vaccine. I understand and agree that information related to my vaccine administration may be recorded in the Utah Statewide Immunization Information System (USIIS). I hereby release Rocky Vista University Southern Utah College of Osteopathic Medicine (RVUSUCOM), and its employees, from all claims arising from such immunizations. We are required to inform you of our privacy practices for the information we collect and keep about you. I have been given a copy of the Rocky Vista University Notice of Privacy Practices and have had an opportunity to ask questions about how my information may be used. I affirm that I have read & agree to all terms stated above.Your Signature is RequiredSignature Date* MM slash DD slash YYYY I certify that I am authorized to legally make health care decisions for the individual whose name appears at the top of this form.*Please type your name in the space below: Signature* Reset signature Signature locked. Reset to sign again Please bring a form of identification to your vaccination appointment.From which manufacturer do you want your vaccination?* Johnson & Johnson Moderna Select a date for your Johnson & Johnson vaccination:*Please select.May 15, 2021May 19, 2021Please schedule your Johnson & Johnson vaccine appointment for May 15, 2021:*Please schedule your Johnson & Johnson vaccine appointment for May 19, 2021:*Select a date for your Moderna vaccination:*Please select.May 15, 2021May 19, 2021Please schedule your Moderna vaccine appointment for May 15, 2021:*Please schedule your Moderna vaccine appointment for May 19, 2021:*We regret to inform you that:Based upon some of your answers, we have determined that you are not eligible for a COVID19 vaccination at this facility. We recommend that you consult your physician before getting the COVID19 vaccine at any other facility and follow their advise. This concludes this form.
