OCEAN HEALTH INITIATIVES INC.
SCREENING QUESTIONAIRE AND CONSENT FOR COVID-19 VACCINE ADMINISTRATION

Full Name: _______________________________	Email: ___________________________________

Phone #: _____________________      Check if it is OK to leave detailed voicemail message at this number.   

Street Address: _____________________________________City: __________________    State: ______

Zip Code: ___________	County: ______________	Municipality: __________________

Date of Birth: _____________________	Birth Country: _________________ Plurality: ____________

Gender: _____________	 Race: _______________	Ethnicity: ___________________

Questions you MUST answer:

1. Are you sick today, ( date)________________?	YES ________		NO ___________

2. Do you have allergies to medications, food, a vaccine component or latex?    YES ______   NO _______

3. Have you received any vaccinations in the past 4 weeks?   YES _____    NO ______

4. Have you ever had a serious reaction after receiving any vaccination?      YES _______     NO_________

5. During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?  YES ______       NO _______

6. For women:  Are you pregnant or is there a chance you could become pregnant during the next month?   YES ________       NO ________

Please provide copies of your driver’s license and medical insurance card.

	Consent: I have received and read the current Emergency Use Fact Sheet. I have been provided an opportunity to ask questions about the disease and the treatment. I understand the risks and benefits of the vaccination. However, as with all vaccines there is no guarantee that I will become immune or that I will not experience side effects.

	I understand that I must wait 15 minutes after receiving my vaccine for safety observation.

Patient Signature: _________________________		Date: __________________