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COVID-19 Vaccination – Step 1

    I am currently under isolation (due to having COVID-19) or under quarantine (due to being exposed to someone with COVID-19)In the past 90 days, I have received monoclonal antibodies or convalescent plasma as part of my COVID-19 treatment, or have been diagnosed with MIS-A or MIS-CI am UNDER 12 years of age (if receiving Pfizer) or UNDER 18 years of age (if receiving Moderna)I have had a severe (anaphylactic) reaction to a previous vaccine or other injectable medicationI have had an allergic reaction of any severity to a previous dose of an mRNA COVID-19 vaccine, any of its components, or to polysorbate

    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 / 30 minutes after the vaccine is administered to be monitored for adverse reactions.

    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.

    *NOTE: Submitting your name on this pageĀ does not result in an appointment. You must find an appointment time and complete your registration on the next page.

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