COVID-19 Vaccine Administration Record
| Do you have allergies to latex, food, medications, or vaccine components? (such as eggs, thimerosal, gelatin, neomycin, phenol, or bovine protein)? | No |
|---|---|
| Did you ever experience any serious reaction after getting a vaccine? | No |
| In the past year, did you receive a transfusion of blood or blood products, or get injected immune (gamma) globulin or any antiviral drug? | No |
| Did you have any brain or other nervous system problems? | Don't know |
| Have you get vaccinated in the last 4 weeks? | No |
| Are your pregnant or planning to get pregnant or your partner is planning to get pregnant? | No |
The COVID-19 vaccine will reduce the risk of being suffering from the new type of Coronavirus disease as known as COVID-19.
Please be aware that the vaccine is not completely effective like all other medicines. It can take a few weeks for your body to build up protection from the vaccine. There is always a chance to get infected by Coronavirus even with the vaccine; however, the vaccine lessens the severity of any infection. Two doses will reduce the chance of being seriously ill and reduce the risk of death due to Coronavirus.
You still need to follow the health instructions in your workplace and in public areas, such as wearing a mask and keeping the distance from others after you received the COVID-19 vaccine.
The vaccine has some side effects as the other vaccines/medicines, but not everyone gets them.
The most likely side effects that you may experience from the vaccine
- Fever
- Pain at the injection site
- Redness and hardness of the skin at the injection site
- Headache
- Muscle aches or pain
- Joint aches or pain
- Fatigue (tiredness)
- Nausea/vomiting
- Chills
- Underarm gland swelling on the side of study vaccination
If you think you are experiencing any side effects, please remain calm and see your doctor immediately.
If you are currently pregnant or planning to get pregnant or your partner is planning to get pregnant; please see your doctor before getting vaccinated.
By signing this form,
I hereby accept that I have read and understood the acknowledgment letter provided above.
I declare that the information I have provided above is correct.
I am giving my full consent to get the COVID-19 vaccine of my own will.
Vaccine Name:
Manufacturer:
Route:
Site:
Dose:
Exp. Date:
Date of EUA:
Lot:
Date & Time of Vaccination:
Name of Vaccine Administrator:
Signature of Vaccine Administrator:
Keep a complete record of your patients’ coronavirus vaccinations with this free COVID-19 Vaccine Administration Record PDF Template! By linking this PDF template to an online form, you can quickly enter patient details and have it populate into your PDF template automatically — ready to download, print, and store in your medical practice’s records as polished, professional PDF documents. Jotform helps keeping PDFs and form data protected with GDPR compliance features, CCPA compliance features, and optional HIPAA features.
Need to customize the look of this COVID-19 Vaccine Administration Record Template? Use our drag-and-drop PDF Editor to add your logo, change fonts and colors, rearrange the layout of the page, and more. You can also customize your attached form, as well as the spreadsheet you use to track your PDF records in Jotform Tables! Stop using pen and paper to track patient vaccinations and do it more efficiently online with a free COVID-19 Vaccine Administration Record.
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These templates are suggested forms only. If you're using a form as a contract, or to gather personal (or personal health) info, or for some other purpose with legal implications, we recommend that you do your homework to ensure you are complying with applicable laws and that you consult an attorney before relying on any particular form.