Surveypoint

Q1

Patient's Full Name:*

First Name

Q2

Patient's Full Name:*

Ml

Q3

Patient's Full Name:*

Last Name

Q4

Date of Birth:*

Q5

Age:*

Q6

Phone Number:*

Q7

Email:*

Q8

Gender:*

Male

Female

N/A

Q9

Ethnicity:*

Hispanic or Latino

Non Hispanic/Latino

Unknown

Prefer not to answer

Q10

Race:*

African American

American Indian

Asian

Caucasian (white)

Native Hawaiian/Other Pacific Islander

Prefer not to answer

Other

Q11

Address:*

Q12

Primary Care Doctor:*

Q13

Doctor City/State:*

Q14

Are you one of the following?*

75 years and older

65 years and older

Essential Worker

First Responder

Healthcare Worker

Person with chronic condition

Resident of a care facility or other group setting

No, I am not any of the above

Q15

What dose of COVID-19 vaccine will this be?*

First Dose

Second Dose

Q16

Please select the correct option below:*

Yes

No

Don't know or N/A

COVID-19 Screening Questions: In the past two weeks, have you tested positive for COVID-19 or are you currently being monitored for COVID-19?

In the past two weeks, have you had a known exposure with anyone who tested positive for COVID-19?

Have you had a new onset of fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, nausea, vomiting, or diarrhea?

Questionnaire for Immunization: Do you feel sick today?

Do you have an allergy to medications, foods, or any vaccines (eggs, gelatin, thimerosal, neomycin, gentamicin, latex, aluminum, preservatives, baker's yeast, etc.)?

Do you carry an EpiPen?

Have you received COVID-19 monoclonal antibodies or convalescent plasma in the last 90 days?

Have you ever had a serious reaction or fainted after receiving any vaccination?

Have you received a vaccine in the last 14 days?

For women: Are you pregnant or planning to become pregnant in the next month?

Q17

Please specify the allergy from Q2 (or N/A if no known allergies):*

Q18

If desired time slot is unavailable, do you wish to be added to a call list if an appointment opens?

Please Select

Yes

No

Q19

Signature of Person to Receive Vaccine & EUA/VIS (or Signature of Parent/Guardian if Patient is < 18 yo)*

Q20

Signature of Acknowledgment of Notice of Privacy Practices:*

Q21

Please take or upload pictures of front & back of ALL medical and prescription insurance cards for billing purposes

Q22

Authorization

Q23

Star Pharmacy -Form Fill

Patient's Full Name:*

Patient's Full Name:*

Patient's Full Name:*

Date of Birth:*

Age:*

Phone Number:*

Email:*

Gender:*

Ethnicity:*

Race:*

Address:*

Primary Care Doctor:*

Doctor City/State:*

Are you one of the following?*

What dose of COVID-19 vaccine will this be?*

Please select the correct option below:*

Please specify the allergy from Q2 (or N/A if no known allergies):*

If desired time slot is unavailable, do you wish to be added to a call list if an appointment opens?

Signature of Person to Receive Vaccine & EUA/VIS (or Signature of Parent/Guardian if Patient is < 18 yo)*

Signature of Acknowledgment of Notice of Privacy Practices:*

Please take or upload pictures of front & back of ALL medical and prescription insurance cards for billing purposes

Authorization

If uninsured, you must check the box below to attest that the following information is true and accurate: