BBVaccine
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Are you Hispanic or Latino?
Are you 12 or older?
We are currently offering COVID-19 Vaccines to those 18 or Older. Ages 12-17 may get the vaccine when accompanied by a guardian. If you do not qualify, we will contact you when it is opened up for more age group categories and provide a link to schedule your appointment.

LEGAL GUARDIAN INFORMATION

If under 18 years old
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Maximum upload size: 134.22MB
Maximum upload size: 134.22MB

COVID-19 SCREENING QUESTIONS

Please check YES or No for each question.
1. Do you have today or have you had at any time in the last 10 days a fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose,nausea, vomiting, or diarrhea?
2. Have you tested positive for and/or been diagnosed with COVID-19 infection within the last 10 days?
3. Have you had a severe allergic reaction (e.g. needed epinephrine or hospital care) to a previous dose of this vaccine or to any of the ingredients of this vaccine?
4. Have you had any other vaccinations in the last 14 days (e.g. influenza vaccine, etc.)?
5. Have you had any COVID-19 Antibody therapy within the last 90 days (e.g. Regeneron, Bamlanivimab, COVID Convalescent Plasma, etc.)?

IMMUNIZATION SCREENING GUIDANCE FOR COVID-19 VACCINE

Please check YES or No for each question.
1. Do you carry an Epi-pen for emergency treatment of anaphylaxis and/or have allergies or reactions to any medications,foods, vaccines or latex?
2. For women, are you pregnant or is there a chance you could become pregnant?
3. For women, are you currently breastfeeding?
4. Do you have dermal fillers?
5. Are you immunocompromised or on a medication that affects your immune system?
6. Do you have a bleeding disorder or are you on a blood thinner/blood-thinning medication?
7. Have you received a previous dose of any COVID-19 vaccine? If yes, which manufacturer’s vaccine did you receive?

CONSENT STATEMENTS FROM PATIENT

Each statement has been checked off for your convenience. Please read each statement and remove the check if it doesn't apply to you.
Your arm WILL be sore after the injection. So we recommend injecting your weaker arm.

INSURANCE

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INSURANCE (DETAILS)

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THIS SECTION IS TO BE COMPLETED BY ADMINISTRATION.

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