Mass Vaccination Event Consent Form
Personal Information
Full Name
Date of Birth
Address
Phone Number
Email Address
Emergency Contact
Name
Phone Number
Relationship
Medical Information
Allergies
Current Medications
Medical Conditions
Vaccine Screening Questions
Have you received a COVID-19 vaccine before?
Are you feeling sick or feverish today?
Are you pregnant or breastfeeding?
Have you had a severe allergic reaction to a vaccine before?
Consent
I have read and understood the information provided. I consent to receive the vaccine.
Signature
Date