Vaccine Administration Record

If you have received a dose of COVID-19 Vaccine before:
3. Have you ever had an allergic reaction to: (This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.)
If uninsured, you must check the box below to attest that the following information is true and accurate:
For uninsured patients, please select at least one of the following that you will bring with you to your appointment.
This is needed in order to have your vaccine administration fee paid for by the United States Health Resources & Services Administration's COVID-19 Program.