COVID-19 Booster Dose Consent Form
Personal Information
Full Name
Date of Birth
Phone Number
Email Address
Address
Medical History
I have previously received a COVID-19 vaccine.
Date of last COVID-19 vaccine (if known)
List any allergies or medical conditions
List all current medications
Consent
I acknowledge that I have read and understood the information regarding the COVID-19 booster dose.
I consent to receive the COVID-19 booster dose.
Signature
Date