VOUCHERS FOR:
 
 
 
 
Additional Languages:
 

COVID-19 Vaccine Screening Form

Please complete the screening information below, then press the “Next” button at the bottom of the page for a printable voucher.
 
Dispense Assist does not retain your protected health information or other personal data that you provide. The only information retained by Dispense Assist is your IP address, which is not directly associated with any of your personal information. You are responsible for the security of any computer you use to input the information. At a minimum, you should clear your browser after you have printed your Voucher.
 
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 to any component of any of the vaccines listed below?
Yes No
    For list of Johnson&Johnson vaccine components, please refer to the Emergency Use Authorization (EUA)  
    For list of Moderna vaccine components, please refer to the Emergency Use Authorization (EUA)  
    For 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.
 
 

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