Please complete this form to the best of your abilities. Once completed, click “submit” at the bottom of the page.
The following questions will help us determine if there is
any reason you should not get the COVID-19 vaccine today.
If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions may be asked. If a question is not clear, please ask your healthcare provider to explain it.
A component of a COVID-19 vaccine including either of the following: