Please complete the screening information below, then press the “Next” button at the bottom of the page for a printable voucher.
 
* The questions in this form are based on criteria for the Moderna vaccine only. This form should not be used to determine eligibility for COVID-19 vaccines from any other manufacturer.
 
Personal Information
  First Name:        
  Address: 
  Address2/Other: 
City:   State/Terr.:  Zip/Postal Code:
  Telephone:  ( ) -
Email: 
Race: 
Ethnicity: 
  Date of Birth:  / /
  Sex:  Male Female
Medical Information*
  1. Is this person experiencing moderate to severe illness and/or a fever?
Yes No
  2. Has this person already received the COVID Vaccine?
Yes No
  3. Has this person had a severe allergic reaction (e.g., anaphylaxis) to any component of the vaccine for either Pfizer-BioNTech or Moderna COVID-19 vaccines?
Yes No
      - For a list of Moderna vaccine components, please refer to the Emergency Use Authorization (EUA) .  
      - For a list of Pfizer vaccine components, please refer to the Emergency Use Authorization (EUA) .  
  4. Has this person received any type of vaccine within the past 14 days?
Yes No
  5. Has this person received passive antibody therapy (monoclonal antibodies or convalescent plasma) as part of COVID-19 treatment within the past 90 days?
Yes No
 
 
 
By checking the "I Agree" box, I acknowledge that I have been offered a copy of the Emergency Use Authorization Fact Sheet and I consent for the vaccine to be given to me or the person named above for whom I am authorized to sign. If there are any questions, please contact your local Health Department.
I Agree
 
 After completing the screening information, press the “Next” button for a printable voucher.