Register for COVID Vaccine The PharmaCare Network

First Name

Last Name

Email address

Phone Number:

I have read the vaccine information link available for The Emergency Use Authorization of The Janssen (Read Here) or for Moderna (Read Here) Covid-19 Vaccines and herby give my consent to the licensed healthcare provider administering the vaccine, as applicable to share my personal, demographic and health condition information in order to provide me with vaccination services for the COVID-19 vaccine. I understand that the health data shared within this questionnaire will be used to determine my eligibility for receiving the COVID-19 vaccination.

Are you a Maryland Resident?

Yes No

I certify that I am at least 18 years of age or older. (Janssen\Moderna vaccines requires 18 years of age or older.)

Yes No

Have you previously received the COVID-19 vaccine?

Yes No

Have you tested positive for COVID-19 within the last 10 days?

Yes No

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

Yes No

I hereby certify and attest that the information provided in this form is accurate to the best of my knowledge.

Covid-19 Vaccination Clinic