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.