Full Name Date of Birth Phone Number Email Address Residential Address

Have you had a severe allergic reaction (e.g., anaphylaxis) to a vaccine or injectable medication? Yes No Do you have any allergies? Are you currently feeling sick? Yes No Are you pregnant or breastfeeding? Yes No N/A

Vaccine to be Administered Dose Number First Dose Second Dose Booster

Medical Conditions (if any)

Consent Statement

I have read or have had explained to me the information about the vaccine. I have had a chance to ask questions and they were answered to my satisfaction. I understand the risks and benefits of receiving this vaccination.

I consent to receive the vaccine.

Date Signature