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Vaccine Type
*
Pediatric Pfizer ( Ages Only 5-11 )
Pfizer Vaccine ( Ages Only 12 & Above)
Moderna ( Ages Only 18 & Above )
Janssen ( Ages Only 18 & Above )
GROUP NAME
First Name
*
Last Name
Date Of birth
*
Gender
Male
Female
Other
Phone
*
INSURANCE INFORMATION
INSURANCE CARD PICTURE
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Email Address
Street Address
City
State/Province
ZIP / Postal Code
Parent/Legal Guardian Name
Are you currently sick with a moderate to high fever, vomiting/diarrhea?
Yes
No
Have you ever had a serious reaction after receiving an immunization including feeling dizzy or fainting?
Yes
No
Do you have chronic health conditions such as heart disease,lung disease,liver disease,asthma,kidney disease, metabolic disease (e.g., diabetes), anemia or other blood disorder?
Yes
No
Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem? Have you been diagnosedwith rheumatoid arthritis, ankylosing spondylitis, Crohn’s disease?
Yes
No
Do you have allergiestolatex,medications,food,orvaccines?(eggs,gelatin,neomycin,polymyxinor thimerosal,polyethyleneglycol).Ifyes,pleaselist:
Yes
No
Haveyoueverhadaseizuredisorder,braindisorder(includingGuillainBarre)oranyothernervoussystem disorders?
Yes
No
For Tdap and adult Td (ONLY): Do you have an open wound, puncture or tissue tear that prompted you to get a tetanus shot?
Yes
No
In the past 3 months have you taken medications that weaken the immune system such ascortisone,prednisone, other steroids or anticancer drugs, or have you had radiation treatments?
Yes
No
For women: are you pregnant or considering becoming pregnant in the next month?
Yes
No
Live Vaccines Only
Are you currently on home infusions or weekly injections?
Yes
No
Have you received any vaccines or skin tests in the past four weeks?
Yes
No
Have you received a blood transfusion, blood products, or immune globulin or antiviral drug in the past year?
Yes
No
Do you have a history of thymus disease or thymectomy? (yellow fever only)
Yes
No
Are you currently taking any antibiotics or antimalarial medications? (Oral typhoidonly)
Yes
No
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Signature
We Take Your Names As Signature
Consent
*
Yes, I agree with the
privacy policy
and
terms and conditions
.
Send Message
Vaccine Type
*
Pediatric Pfizer ( Ages Only 5-11 )
Pfizer Vaccine ( Ages Only 12 & Above)
Moderna ( Ages Only 18 & Above )
Janssen ( Ages Only 18 & Above )
GROUP NAME
First Name
*
Last Name
Date Of birth
*
Gender
Male
Female
Other
Phone
*
INSURANCE INFORMATION
INSURANCE CARD PICTURE
Drag and Drop (or)
Choose Files
Email Address
Street Address
City
State/Province
ZIP / Postal Code
Parent/Legal Guardian Name
Are you currently sick with a moderate to high fever, vomiting/diarrhea?
Yes
No
Have you ever had a serious reaction after receiving an immunization including feeling dizzy or fainting?
Yes
No
Do you have chronic health conditions such as heart disease,lung disease,liver disease,asthma,kidney disease, metabolic disease (e.g., diabetes), anemia or other blood disorder?
Yes
No
Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem? Have you been diagnosedwith rheumatoid arthritis, ankylosing spondylitis, Crohn’s disease?
Yes
No
Do you have allergiestolatex,medications,food,orvaccines?(eggs,gelatin,neomycin,polymyxinor thimerosal,polyethyleneglycol).Ifyes,pleaselist:
Yes
No
Haveyoueverhadaseizuredisorder,braindisorder(includingGuillainBarre)oranyothernervoussystem disorders?
Yes
No
For Tdap and adult Td (ONLY): Do you have an open wound, puncture or tissue tear that prompted you to get a tetanus shot?
Yes
No
In the past 3 months have you taken medications that weaken the immune system such ascortisone,prednisone, other steroids or anticancer drugs, or have you had radiation treatments?
Yes
No
For women: are you pregnant or considering becoming pregnant in the next month?
Yes
No
Live Vaccines Only
Are you currently on home infusions or weekly injections?
Yes
No
Have you received any vaccines or skin tests in the past four weeks?
Yes
No
Have you received a blood transfusion, blood products, or immune globulin or antiviral drug in the past year?
Yes
No
Do you have a history of thymus disease or thymectomy? (yellow fever only)
Yes
No
Are you currently taking any antibiotics or antimalarial medications? (Oral typhoidonly)
Yes
No
Upload Signature
Drag and Drop (or)
Choose Files
Signature
We Take Your Names As Signature
Consent
*
Yes, I agree with the
privacy policy
and
terms and conditions
.
Send Message
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