Community Registration General Public Registration General Public Registration THIS SECTION IS TO BE COMPLETED BY ADMINISTRATION. Last Name First Name Date of birth * Sex * M F U "M" Male - "F" Female - "U" Unknown Email Street Address City * State * AL AK AS AZ AR CA CO CT DE DC FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PA PR RI SC SD TN TX UT VT VA VI WA WV WI WY VI Zipcode * FL County Of Residence * ALACHUA BAKER BAY BRADFORD BREVARD BROWARD CALHOUN CHARLOTTE CITRUS CLAY COLLIER COLUMBIA DADE DESOTO DIXIE DUVAL ESCAMBIA FLAGLER FRANKLIN GADSDEN GILCHRIST GLADES GULF HAMILTON HARDEE HENDRY HERNANDO HIGHLANDS HILLSBOROUGH HOLMES INDIAN RIVER JACKSON JEFFERSON LAFAYETTE LAKE LEE LEON LEVY LIBERTY MADISON MANATEE MARION MARTIN MONROE NASSAU OKALOOSA OKEECHOBEE ORANGE OSCEOLA PALM BEACH PASCO PINELLAS POLK PUTNAM SANTA ROSA SARASOTA SEMINOLE ST. JOHNS ST. LUCIE SUMTER SUWANNEE TAYLOR UNION UNKNOWN VOLUSIA WAKULLA WALTON WASHINGTON OUT-OF-STATE Phone Race * BLACK WHITE ASIANIND ASIANOTH OTHER UNKNOWN Are you Hispanic or Latino? * Y N U "Y" Yes - "N" No - "U" Unknown Vaccine Expiration Date Vaccine Expiration Date Which arm do you want the injection in? LA RA "LA = LEFT ARM" - "RA = RIGHT ARM" (Your arm WILL be sore after the injection. So we recommend injecting your weaker arm.) Are you or the patient 6 months of age or older? Yes No We are currently offering COVID-19 Vaccines to those 18 or Older. Ages 6 months -17 years old may get the vaccine when accompanied by a guardian. If you do not qualify, we will contact you when it is opened up for more age group categories and provide a link to schedule your appointment. LEGAL GUARDIAN INFORMATION If under 18 years old Name Name Name Name Upload Drivers License (Front Side) Drop a file here or click to upload Choose File Maximum upload size: 516MB Upload Drivers License (Back Side) Drop a file here or click to upload Choose File Maximum upload size: 516MB COVID-19 SCREENING QUESTIONS Please check YES or No for each question. 1. Do you have today or have you had at any time in the last 10 days a fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose,nausea, vomiting, or diarrhea? * YesYes No 2. Have you tested positive for and/or been diagnosed with COVID-19 infection within the last 10 days? * Yes No 3. Have you had a severe allergic reaction (e.g. needed epinephrine or hospital care) to a previous dose of this vaccine or to any of the ingredients of this vaccine? * Yes No 4. Have you had any other vaccinations in the last 14 days (e.g. influenza vaccine, etc.)? * YesYes No 5. Have you had any COVID-19 Antibody therapy within the last 90 days (e.g. Regeneron, Bamlanivimab, COVID Convalescent Plasma, etc.)? * YesYes No IMMUNIZATION SCREENING GUIDANCE FOR COVID-19 VACCINE Please check YES or No for each question. 1. Do you carry an Epi-pen for emergency treatment of anaphylaxis and/or have allergies or reactions to any medications,foods, vaccines or latex? Yes No 2. For women, are you pregnant or is there a chance you could become pregnant? Yes No 3. For women, are you currently breastfeeding? Yes No 4. Do you have dermal fillers? Yes No 5. Are you immunocompromised or on a medication that affects your immune system? Yes No 6. Do you have a bleeding disorder or are you on a blood thinner/blood-thinning medication? Yes No 7. Have you received a previous dose of any COVID-19 vaccine? If yes, which manufacturer’s vaccine did you receive? * If Yes, What Manufacturer?If Yes, What Manufacturer? No CONSENT STATEMENTS FROM PATIENT Each statement has been checked off for your convenience. Please read each statement and remove the check if it doesn't apply to you. I certify that I am: (a) the patient and at least 16 years of age; (b) the legal guardian of the patient and confirm that the patient is at least 16 years of age; or (c) legally authorized to consent for vaccination for the patient named above. Further, I hereby give my consent to the Florida Department of Health (DOH) or its agents to administer the COVID-19 vaccine. I understand that this product (Pfizer/Moderna) has been approved or licensed by FDA. Prevent Coronavirus Disease 2019 (COVID-19) for use in individuals either 16 years of age or older or 18 years of age and older. I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccine(s). I understand the risks and benefits associated with the above vaccine and have received. I also acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction. I acknowledge that I have been advised to remain near the vaccination location for approximately 15 minutes (or more in specific cases) after administration for observation. If I experience a severe reaction, I will call 9-1-1 or go to the nearest hospital. On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless the State of Florida, the Florida Department of Health (DOH), the Florida Division of Emergency Management (FDEM) and their staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the vaccine listed above. I acknowledge that: (a) I understand the purposes/benefits of Florida SHOTS, Florida’s immunization registry and (b) DOH will include my personal immunization information in Florida SHOTS and my personal immunization information will be shared with the Centers for Disease Control (CDC) or other federal agencies. I acknowledge receipt of the DOH Notice of Privacy Practices. DO YOU HAVE INSURANCE? Yes No INSURANCE Which insurance do you have? Medicaid Medicare Florida Blue Other Which insurance do you have? Type Of Plan HMO PPO Non PPO Other Type Of Plan Name of Insured Policy # Group # Upload Front Of Isurance Card Drop a file here or click to upload Choose File Maximum upload size: 516MB Upload Back Of Isurance Card Drop a file here or click to upload Choose File Maximum upload size: 516MB Upload License or ID Drop a file here or click to upload Choose File Maximum upload size: 516MB If you are human, leave this field blank. Submit ADMINISTRATION LOGIN
