Vaccine Administration Form

CHA Revere Vaccine Administration Form

Informed consent for vaccination
Please use this secure webform to answer the following questions. Please note, all information provided will be protected.
Name*

First NameLast Name
Date of birth*

MonthDayYear
Age*
Gender*

MaleFemaleOtherUnknown
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I want to receive the following vaccination (s)*

FluShingrixRSVCovid-19Other
Do you feel sick today?*

YesNoDon't know
Do you have any health condition, such as heart disease, diabetes or asthma?*

YesNoDon't know
If you answered yes above, please list your health condition.
Do you have any allergies to latex, medications, food, or vaccines?*

YesNoDon't know
If you answered yes above, please list your allergies.
Have you ever had a reaction after having a vaccination, including fainting or feeling dizzy?*

YesNoDon't know
Have you ever had a seizure disorder, a brain disorder, Guillain-Barré syndrome or other nervous system problems?*

YesNoDon't know
If you answered yes above, please list your nervous system problems.
Signature*

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CHA Revere Vaccine Administration Form