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COVID-19 Vaccination – Second Dose

    I have had a vaccination within the past 14 daysI am currently under isolation (due to having COVID-19) or under quarantine (due to being exposed to someone with COVID-19)I have received monoclonal antibodies or convalescent plasma in the past 90 days as part of my COVID-19 treatmentI am UNDER 16 years of age (if receiving Pfizer) or UNDER 18 years of age (if receiving Moderna)I have had a severe reaction reaction to a previous vaccine or other injected medicationAfter receiving my previous COVID-19 vaccine I developed one or more of the following within 15-30 minutes: feeling of impending doom; itching, hives, flushing, or swelling; confusion, disorientation, dizziness, lightheadedness, weakness, or loss of consciousness; shortness of breath, wheezing, bronchospasm, stridor, or hypoxia; decrease in blood pressure or racing heartrate; nausea, vomiting, abdominal cramps, or diarrhea)

    Please read the HIPAA Notice of Privacy Policy
    Received the Gwinnett, Newton, and Rockdale HIPAA NOTICE of Privacy Policy

    Please read the Pfizer EUA Fact Sheet
    Please read the Moderna EUA Fact Sheet
    I read and understand the above EUA fact sheets and understand the benefits and risks of the COVID-19 vaccine.

    I agree to remain onsite for 15 minutes after the vaccine is administered to be monitored for adverse reactions.

    I am currently NOT pregnant OR I am pregnant AND have written approval from my Obstetrician to receive this vaccine (I must bring this written approval to my appointment)

    Full Name:

    Unfortunately, you are not currently eligible to receive a COVID-19 vaccination. Please contact your primary care provider to determine when you are eligible.