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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
  Are you allergic to a COVID-19 vaccine or any of its ingredients?
  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?
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