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Covid 19 Moderna Vaccination Consent And Release

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COVID-19 Moderna Vaccination Consent and Release

COVID-19 Moderna Vaccination Consent and Release Form is used to get online Moderna vaccination appointments

Page 1

Please read and complete the following consent and release form before receiving the Moderna COVID-19 vaccine.

Email*

Full Name*

Date of Birth*

Address*

City*

State*

Zip Code*

Phone Number*

Emergency Contact Name*

10.

Emergency Contact Phone Number*

11.

Do you have a history of sev...*

Yes

12.

Have you ever had a severe a...*

Yes

13.

Have you ever had a severe a...*

Yes

14.

Have you received any vaccine in the past 14 days?*

Yes

15.

Have you received passive an...*

Yes

16.

Do you have a weakened immune system?*

Yes

17.

Are you pregnant or breastfeeding?*

Yes

18.

Do you have a bleeding disor...*

Yes

19.

Do you have a fever?*

Yes

20.

Have you ever tested positive for COVID-19?*

Yes

21.

Have you received any vaccine in the past 14 days?*

Yes

22.

Do you have a history of Guillain-Barre Syndrome?*

Yes

23.

Do you have a history of Bell's Palsy?*

Yes

24.

Do you have a history of seizures?*

Yes

25.

Do you have a history of fainting or syncope?*

Yes

26.

Do you have a history of heart disease?*

Yes

27.

Do you have a history of lung disease?*

Yes

28.

Do you have a history of kidney disease?*

Yes

29.

Do you have a history of liver disease?*

Yes

30.

Do you have a history of diabetes?*

Yes

31.

Do you have a history of cancer?*

Yes

32.

Do you have a history of HIV/AIDS?*

Yes

33.

Do you have a history of autoimmune disease?*

Yes

34.

Do you have a history of stroke?*

Yes

35.

Do you have a history of blood clots?*

Yes

36.

Do you have a history of bleeding problems?*

Yes

37.

Do you have a history of any...*

Yes

38.

Please list any other medical conditions you have:

Description:Get your Moderna COVID-19 vaccine appointment with ease using our online Consent and Release Form. This form ensures that you are aware of the risks and benefits of the Moderna vaccine and gives your consent to receive it.

Protect yourself and your loved ones by getting vaccinated against COVID-19. Our COVID-19 Moderna Vaccination Consent and Release Form is designed to make the process of getting vaccinated as easy as possible. By filling out this form, you will be able to schedule your Moderna vaccine appointment online and provide your consent to receive the vaccine. The form includes important information about the vaccine, including its risks and benefits, and ensures that you are fully informed before receiving the vaccine. Our goal is to make the vaccination process as safe and efficient as possible, and our Consent and Release Form is an important part of that effort. So don't wait - fill out the form today and take the first step towards protecting yourself and your community from COVID-19.

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