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Long Beach Island COVID-19 Vaccination Registration

Registration Form
(MM-DD-YYYY)  
  Do you have medicare?
  Do you have other insurance?
  Do you require a handicap ramp for access?
No out of pocket expense for vaccine, insurance information is requested to help offset the cost of providing this service to you as the resident.
COVID-19 Questionnaire
  Have you had ANY vaccine in the last 60 days?
  Are you currently taking antibiotics or antiviral medications to treat an acute infection?
  Are you currently in isolation or quarantine due to COVID-19?
  Do you have a fever or ≥100.4 degrees Fahrenheit?
  Have you had a severe allergic reaction to any vaccine, injectable medication, or any other cause or do you carry an epi-pen?
  Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as a treatment for COVID-19 in the past 90 days?
  Are you immunocompromised?
  Do you have a bleeding disorder or are you taking a blood thinner?
  Do you have a history of or a risk for a blood clotting disorder?
  Pregnant or breastfeeding?
  Do you have a history of Guillain-Barre syndrome?
  Have you been previously vaccinated for Covid-19?
Flu Questionnaire
  Are you sick today?
  Have you had a flu shot in the past?
  Do you have any allergies to medication/food/vaccine component/latex?
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