Facebook Twitter Youtube Linkedin-in Instagram
MyChart
Donate Now
Pay Now

Covid-19 Vaccination Application Form

"*" indicates required fields

MM slash DD slash YYYY
Gender*
Address*
Zip Code

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.

MEDICAL HISTORY
Do you have allergies to latex, food, medications, or vaccine components? (such as eggs, thimerosal, gelatin, neomycin, phenol, or bovine protein)?*
Did you ever experience any serious reaction after getting a vaccine?*
In the past year, did you receive a transfusion of blood or blood products, or get injected immune (gamma) globulin or any antiviral drug?*
Did you have any brain or other nervous system problems?*
Have you get vaccinated in the last 4 weeks?*
Are your pregnant or planning to get pregnant or your partner is planning to get pregnant?*
Do you have any of the followings? (select all that apply)*
Image size is too small for OCR Engine 2. Please use Engine 1.*
Have you ever tested positive for COVID-19?*
In the last 14 days, have you contacted with a person who was confirmed to have COVID-19?*
In the last 14 days, have you travelled internationally?*
Do you have any of the followings?*

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.

MM slash DD slash YYYY

Broward Community & Family Health Centers, Inc. is a FTCA deemed facility. This is a Health Center Program grantee under 42 U.S.C. 254b, and a deemed Public Health Service employee under 42 U.S.C. 233(g)-(n). For further information on our FTCA status, please contact BCOM Corporate Office at (954) 266-2999.

Quick Links

Contact Us

5010 Hollywood Blvd.
Hollywood, FL 33021

Tel:  (954) 266-2999
Fax: (954) 966-3320

© 2022 Broward Community & Family Health Centers Inc | Designed by Global Presence Health