COVID-19 Booster Vaccine Registration

Please enter your PPSN *

What is your age? *

Have you had a serious allergic reaction (anaphylaxis) that needed medical treatment: I) after having a previous dose of the Moderna (Spikevax®) or Pfizer/BioNTech (Comirnaty®) COVID-19 vaccine, OR II) to any of the vaccine ingredients, including polyethylene glycol known as PEG? *

Yes
No

Have you ever had a serious allergic reaction (anaphylaxis) to Trometamol (a contrast dye used in MRI radiological studies)? *

Yes
No

Have you ever had a serious allergic reaction (anaphylaxis): I) after taking multiple different medications, with no reason known for the reaction. OR II) after having a vaccine or a medicine that contains polyethylene glycol (PEG), OR III) for unexplained reasons? *

Yes
No

Have you ever had Mastocytosis (rare condition caused by an excess number of mast cells gathering in the body's tissues) OR II) idiopathic anaphylaxis. This is a condition diagnosed by an immunologist. OR III) a serious allergic reaction (anaphylaxis) due to food, medication or venom from an insect or animal? *

Yes
No

Have you ever had myocarditis (inflammation of the heart muscle) after having a previous dose of the Moderna (Spikevax®) or Pfizer/BioNTech (Comirnaty®) COVID-19 vaccine? *

Yes
No

Have you ever had pericarditis (inflammation of the lining around the heart) after having a previous dose of the Moderna (Spikevax®) or Pfizer/BioNTech (Comirnaty®) COVID-19 vaccine? *

Yes
No

If you answered yes on the previous question and had pericarditis (inflammation of the lining around the heart) after a previous dose of the Moderna (Spikevax®) or Pfizer/BioNTech (Comirnaty®) COVID-19 vaccine, has your COVID-19 vaccination been approved by a specialist doctor? *

Yes
No
N/A

Have you been tested positive (with a PCR test) in the last 6 months for COVID-19 since you were fully vaccinated with a course of COVID-19 vaccine? *

Yes
No

Do you have a bleeding disorder or are you on anticoagulation therapy? *

Yes
No

Have you already received an additional dose or booster dose (after your initial primary vaccination course) in the last 3 months? *

Yes
No

Are you pregnant? *

Yes
No

Do you consent to vaccination with COVID-19 Booster Vaccine? *

Yes
No

Name *

First

Last

Email *

Phone Number *

Date Of Birth *

Register for a COVID_19 Booster Vaccine