Vaccination - Washington County COVID-19 Response

Patient Demographic Information

Last Name*

First Name*

Middle Initial

Date of Birth*

Sex*

Male
Female
Transgender
Other

Race*

Hispanic Ethnicity*

Yes
No
Unknown
Refused

Address*

Street Address Address Line 2 City State ZIP Code

Primary Phone*

Mobile Phone

required if requesting text notifications

Email

Would like a reminder for the next appointment*

Yes
No

Receive reminder as:

Call
Text
Email

Insurance Type*

Private or Employer Insurance
Underinsured
Uninsured
Medicaid
Medicare

Please Upload Insurance

jpg, gif, png, or pdf files accepted.

Accepted file types: jpg, gif, png, pdf, Max. file size: 64 MB.

Health History

1. Are you feeling sick today?*

Yes
No
Unknown

2. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something? For example, a reaction for which you were treated with epinephrine or Epi Pen or for which you had to go to the hospital?*

Yes
No
Unknown

3. Have you ever had a serious reaction after any vaccination or injectable medication including a previous dose of the COVID-19 vaccine?*

Yes
No
Unknown

4. In the past 14 days have you had contact with a confirmed COVID-19 patient?*

Yes
No
Unknown

5. Are you breastfeeding or pregnant?*

Yes
No
Unknown

6. Have you received passive antibody therapy as a treatment for COVID-19?*

Yes
No
Unknown

7. Are you immunocompromised? (taking medication or being treated for cancer, leukemia, HIV/AIDS or other immune system problems or taking medication that affects your immune system)*

Yes
No
Unknown

8. Do you have a bleeding disorder or are you taking a blood thinner?*

Yes
No
Unknown

9. Have you ever received a dose of COVID-19 vaccine?*

Yes
No
Unknown

How many vaccines Have you received?*

One
Two

What type of Vaccine?*

Pfizer
Moderna

Date of First Vaccine?*

Date of Second Vaccine?*

10. Have you received any vaccination within the last 14 days?*

Yes
No
Unknown

Date of First Vaccine?*

What type of Vaccine?*

Pfizer
Moderna

Please list any health issues that may put you in a higher risk category.

Such as hypertension, diabetes, other autoimmune, BMI >40