Before we schedule your vaccine

For the safety of other customers and our employees, let's first get these familiar questions out of the way. Please answer this brief COVID-19 questionnaire for the person being scheduled. All fields are required.

Email Address

Phone Number

In the past 14 days, have you tested positive for COVID-19?
In the past 14 days, have you been in close contact with anyone who tested positive for COVID-19?
Have you ever received a dose of COVID-19 vaccine?
If yes which vaccine product did you receive?
Have you ever had an allergic reaction to?

_{(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.)}
_{Note: A component of a COVID-19 vaccine including either of the following:}
_{Polyethylene glycol(PEG), which is found in some medications, such as laxatives and preparation for colonoscopy procedures.}
_{Polysorbate, which is found in some vaccines, film coated tablets, and intravenous steroids.}
_{A previous dose of COVID-19 vaccine.}
_{A vaccine or injectable therapy that contains multiple components, one of which is COVID-19 vaccine component, but it is not known which component elicited the immediate reaction.}

Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?
_{(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.)}
Do you currently have fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, nausea, vomiting, or diarrhea?
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