Informed Consent Form for SARS-CoV-2 (COVID-19) Immunization Use this online tool to be added to the waitlist for the first dose of the COVID-19 vaccine. COVID-19 vaccinations are only available to those who meet federal and state criteria. Currently, the vaccine is available to healthcare personnel, first responders, and people 60 years or older. If you do not meet eligibility criteria you will not be able to receive a vaccine at this time. Please continue to monitor your eligibility status as guidelines change. Patient InformationWho is receiving the vaccine?*Please enter your full legal name. First Middle Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920AgePhone Number*EmailYour email address is not required but is requested. We will send you a copy of this information if you include your email address. Enter Email Confirm Email Legal Sex*Please select your genderMaleFemaleUnknownSocial Security NumberHome Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency ContactEmergency Contact Name* First Last Phone Number*Relationship to Patient*MotherFatherSpousePrimary Care ProviderDo you have a Primary Care Provider?*YesNoPrimary Care Provider Name*Primary Care Provider Phone NumberScreening QuestionsDo you have any allergies (e.g., medications, foods, or latex)?*YesNoAllergies*Have you ever had a serious reaction or fainted after receiving any vaccination?*YesNoIf yes, please explainAre you immune-compromised or are you on a medicine that affects your immune system?*YesNoIf yes, type of medicationDo you have a bleeding disorder or are you on a blood thinner?*YesNoIf yes, type of blood thinnerHave you previously received a COVID-19 vaccine?*YesNoIf this is your second dose of this Covid-19 vaccine, did you have an allergic reaction to the first dose?*YesNoPlease explain*Have you received any vaccinations in the past 4 weeks?*YesNoIf yes, which vaccines?*Are you pregnant or are you considering becoming pregnant in the next month?*YesNoAre you breastfeeding?*YesNoLiving WillDo you have a Living Will?*YesNoWould you be interested in receiving information on a living will?*YesNoDoes Ephraim McDowell Health have a copy of your Living Will on file?*YesNoHealthcare Power of Attorney (POA) or Healthcare SurrogateDo you have a Healthcare Power of Attorney (POA) or Healthcare Surrogate?*YesNoWould you be interested in receiving information on a Healthcare Power of Attorney (POA) or Healthcare Surrogate?*YesNoDoes Ephraim McDowell Health have a copy of your Healthcare Power of Attorney (POA) or Healthcare Surrogate on file?*YesNoName of Agent*Relationship*End SectionPatient Consent IDNameThis field is for validation purposes and should be left unchanged.