COVID-19 VACCINATION REGISTRATION FORM

Please complete the registration packet. Call (937) 651-6244 to be added to the COVID-19 waiting list. LCHD will call
you to schedule an appointment. Bring the completed registration packet to your appointment. Do not drop off your
packet to LCHD prior to your appointment.

PATIENT INFORMATION:
First Name: _________________________ MI: ____________ Last Name: ________________________________
Gender: M F (circle one) Date of Birth: __________________ Phone number: _______________________
Address: Street: _______________________________City: ______________________________ZIP: _________
Email: _____________________________________________ Race: ___________ Ethnicity: ______________

INSURANCE INFORMATION: Please provide your insurance information for the services. Due to the
Pandemic, no patient out of pocket cost will be required.

Insurance Info: Primary Card Holder Name: _______________________________________________________

Card Holder Date of Birth: ________________________ Card Holder Employer: ___________________________
Insurance Company_______________________________________________________________________
Member ID: ____________________________________ Group #________________________________________
Name of Insured if different than Registrant: ________________________________________________________
Relationship to Insured: _______________________________________________________________________

Your signature on this form gives us permission to bill your insurance for the administration fee.

SIGNATURE: ___________________________________________________________ Date: ___________________

Bring the completed packet to your COVID-19 Vaccine appointment.

For LCHD Use Only

Date Vaccine Lot# RA LA RT LT 0.3 ML 0.25 ML 0.5 ML LCHD RN

Moderna / Pfizer

Moderna / Pfizer
 COVID-19 VACCINE HEALTH QUESTIONNAIRE
COMPLETE THIS QUESTIONNAIRE THE DAY OF YOUR COVID-19 VACCINE APPOINTMENT
The following questions will help us determine if there is any reason we should not give you the Moderna COVID-19
Vaccine today. If you answer “yes” to any questions, it does not necessarily mean you should not be vaccinated. It just
means additional questions must be asked. If a question is not clear, please ask your healthcare provider to explain it.

Please Answer the Following Questions: Yes No

Are you sick today?
Have you ever had a severe allergic reaction to a medication or vaccine?*
*If yes, please call ahead to discuss your eligibility to be vaccinated at LCHD – (937) 592-9040, Option 6
Do you have a bleeding disorder or take blood thinners?
Are you immunocompromised (ie., HIV/AIDS, Bone Marrow Transplant, Cancer, Lupus)?
Do you take medication that affects your immune system (ie, Medications for Rheumatoid
Arthritis, Cancer Treatments, Psoriasis)?
Are you pregnant or breastfeeding?
Have you received another COVID-19 vaccine?
Have you received any other vaccine in the past 14 days?
Have you received passive antibody therapy (monoclonal antibodies or convalescent
plasma) as part of COVID-19 treatment in the last 90 days?

I have received a copy and have read or been read to me the information contained in the appropriate EUA about the disease(s) and
vaccine(s) checked above. I have had a chance to ask questions which were answered to my satisfaction. I understand the benefits
and risks of the vaccine and ask that the vaccine indicated on this record be given to me or the person named for whom I am
authorized to make this request. I have been advised to wait 15 minutes after the injection to monitor for signs and symptoms of an
allergic reaction. I also grant permission for this record to be released/faxed to providers, health departments, school, day-care
centers, community and state immunization registry databases and others as is necessary, per HIPAA standards. I have been given
the opportunity to read the Logan County Health District (LCHD) HIPAA Notice of Privacy Practices. Further this written release is
good for 5 years, unless I notify LCHD in writing of something different.

____________________________________________________________ _____________________________
Patient Signature Date

____________________________________________________________
Parent/Legal Guardian Signature (If Applicable)

____________________________________________________________
LCHD RN