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Cornerstone Care COVID-19 Vaccine - Rogersville

Patient First Name

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Patient Last Name

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County of Residence*

Greene

Washington

Allegheny

Fayette

Monongalia (WV)

Other

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*If other please state

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Your Phone Number (XXX-XXX-XXXX)

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Phone Type*

Home

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Date of Birth

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Do you certify that you are at least 18 years old?*

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No

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Gender*

Male

Female

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Marital Status*

Married

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Domestic Partner

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Mailing Address

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City, State, and Zip

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Email Address

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Race*

American Indian or Alaska Native

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Cultural Origin*

Hispanic/Latino

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Preferred Language

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Language Barrier*

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No

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Homeless Status:*

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Shelter

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Migrant Worker Status:*

YES

NO

Seasonal

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Public Housing*

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No

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Veteran Status*

Yes

No

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Are you a current Cornerstone Care Patient?*

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No

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Your Current Primary Care Provider (Office, Doctor, Nurse Practitioner, Physician Assistant, etc)

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Your Current Dentist

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Are you sick today?*

Yes

No

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Have you been diagnosed with COVID-19 within the past 3 months by PCR or antigen testing or are you currently awaiting the results of a COVID test?*

Yes

No

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In the past two weeks, have you had contact with anyone who tested positive for COVID-19?*

Yes

No

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In the last 10 days, have you had a fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle aches, headache, new loss of taste or smell, sore throat, nausea, vomiting or diarrhea?*

Yes

No

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Have you had a severe reaction (such as hives or difficulty breathing) to any previous vaccine?*

Yes

No

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Do you have severe allergies to any medications, food, insect bites or a previous history of anaphylactic reaction or have you peen prescribed an EpiPen for any reason?*

Yes

No

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Are you actively being treated for any immunocompromising diseases such as cancer, lupus, rheumatoid arthritis or any other autoimmune disease?*

Yes

No

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For women, are you pregnant, is there a chance you could become pregnant within the next two months after this vaccine dose, or are you breastfeeding?*

Yes

No

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If you answered "Yes" to any of the above, please specify the details here:

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Do you certify that you have answered all screening questions accurately and to the best of your ability?*

Yes

No

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The Moderna Vaccine comes in 10-dose vials, so we are scheduling vaccine appointments in batches of 10. Are you interested in being added to a "Standby" list for the location selected above, so that if we have a no-show, we can call you to come in within 60 minutes to receive a vaccine so it does not go to waste?*

Yes

No

Tentatively Yes (but it depends on the day of the week or time of day.)

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Would you like to be added to the standby list for additional locations?*

Yes

No

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