COVID Pre-Vaccination Screening Form

For COVID Vaccine Recipients:

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.

You will receive a copy of your answers in a PDF format along with additional vaccine information to the email you provide below.

If you prefer to download the COVID Pre-Vaccination Screening Form to print and fill out, instead of filling out this online form, you may do so by clicking the Download button below.



    Yes No Don't Know


    Yes No Don't Know


    Pfizer
    Moderna
    Other


    Yes No Don't Know


    Yes No Don't Know


    Yes No Don't Know


    Yes No Don't Know


    Yes No Don't Know


    Yes No Don't Know


    Yes No Don't Know


    Yes No Don't Know


    Yes No Don't Know