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Patient Form
**READ FIRST: Fill in below to register, this is a 2 step process, fill out the form below and then you will be redirected to a second form. You must fully complete both sections to be officially registered**
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Have you ever received a dose of COVID-19 vaccine?
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If yes, which vaccine product did you receive?
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Have you ever had an allergic reaction to:
A component of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures
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Polysorbate
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Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?
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(This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.)
Have you received any vaccine in the last 14 days?
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Have you ever had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?
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Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?
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Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
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Do you have a bleeding disorder or are you taking a blood thinner?
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What to Expect from the Moderna Vaccine
COVID-19 vaccination will help protect you from getting COVID-19. You may have some side effects, which are normal signs that your body is building protection. These side effects may feel like flu and may even affect your ability to do daily activities, but they should go away in a few days. Common side effects Helpful tips If you have pain or discomfort, talk to your doctor about taking an over-the-counter medicine, such as ibuprofen or acetaminophen. On the arm where you got the shot: Pain Swelling To reduce pain and discomfort where you got the shot: * Apply a clean, cool, wet washcloth over the area. * Use or exercise your arm. When to call the doctor To reduce discomfort from fever: * Drink plenty of fluids. * Dress lightly. Ask your healthcare provider about getting started with v-safe Use your smartphone to tell CDC about any side effects after getting the COVID-19 vaccine. You’ll also get reminders if you need a second dose Learn more about v-safe. www.cdc.gov/vsafe In most cases, discomfort from fever or pain is normal. Contact your doctor or healthcare provider: * If the redness or tenderness where you got the shot increases after 24 hours * If your side effects are worrying you or do not seem to be going away after a few days Remember Side effects may feel like flu and even affect your ability to do daily activities, but they should go away in a few days. With most COVID-19 vaccines, you will need 2 shots in order for them to work. Get the second shot even if you have side effects after the first one, unless a vaccination provider or your doctor tells you not to get a second shot. It takes time for your body to build protection after any vaccination. COVID-19 vaccines that require 2 shots may not protect you until a week or two after your second shot. It’s important for everyone to continue using all the tools available to help stop this pandemic as we learn more about how COVID-19 vaccines work in real-world conditions. Cover your mouth and nose with a mask when around others, stay at least 6 feet away from others, avoid crowds, and wash your hands often.
Expressed Consent
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Yes, I have read the "What to Expect from the Moderna Vaccine"
My signature below provides Dr. Keith Newby/Fort Norfolk Medical Associates with permission to utilize this data to create a local, state, or federal electronic record of my information for the purpose of administration and reporting of COVID Vaccine activities.
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Yes
Interested in Volunteering COVID-19 vaccine?
Moderna Volunteer
Interested in receiving the COVID-19 vaccine?
Moderna Vaccine Fact Sheet
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