COVID-19 Vaccination Request IMPORTANT: This form is adult appointments only. If you would like to make a vaccination appointment for a child age 5-17, please use our pediatric request form. Step 1 of 6 - Personal Information 16% Please do not submit duplicate registration requests as this may delay processing of your request. Personal InformationName* Legal First Name Legal Last Name Date of Birth Date Format: MM slash DD slash YYYY Date of Birth*SSNGender*-Select-MaleFemaleTransgender, male-to-femaleTransgender, female-to-maleNon-binary, male birthNon-binary, female birthPrefer Not to SpecifyWeightPlease enter a number from 1 to 999.Ethnicity*-Select-Hispanic or LatinoNot Hispanic or LatinoUnknownRace*-Select-Native American or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Pacific IslanderOtherUnknown or Not ReportedWhite/CaucasianAre you a University of Kentucky HMO/PPO/EPO/RHP/SAVER member:*YesNo Contact InformationAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Enter Email Confirm Email If you do not have an email address please enter: firstname.lastname@example.org Occupation InformationIs the person wanting to be vaccinated a University of Kentucky student or employee?*YesNoI am a...*UK HealthCare EmployeeUniversity of Kentucky EmployeeUniversity of Kentucky StudentUK ID* Medical InformationWill this be your first, second, third, fourth dose?*-Select-This will be my first dose/shot of the vaccine.This will be my second dose/shot of the vaccine.This will be my third dose/shot of the vaccine.This will be my fourth dose/shot of the vaccine.Which vaccine did you receive?*-Select-Pfizer-BioNTechModernaJ&JDate of first vaccine dose*Date of second vaccine dose*Date of third vaccine dose*During the past 90 days, have you received passive antibody therapy for COVID-19?*YesNo Vaccination Consent QuestionnaireAre you sick today, have a fever, a rash or Shingles?*YesNoPlease provide more details*Do you have allergies to ANY medication, food (e.g. eggs, nuts), latex or any vaccine component (e.g.neomycin, formaldehyde, gentamicin, thimerosal, bovine protein, phenol, polymyxin, gelatin, baker’s yeast or yeast)?*YesNoPlease provide more details*Have you ever had a serious reaction after receiving a vaccination?*YesNoPlease provide more details*Have you had the vaccine(s) you are receiving today before?*YesNoPlease provide more details*Have you received any vaccinations or skin tests in the past 4 weeks?*YesNoPlease provide more details*Have you had seizures, Guillain-Barre Syndrome (GBS), or any neurological or brain disorder?*YesNoPlease provide more details*Are you pregnant, breastfeeding or do you plan on becoming pregnant in the next three months?*YesNoPlease provide more details*Are you a cigarette smoker or have diabetes, alcoholism or low immune system, cerebrospinal fluid leak, Cochlear implant, chronic heart, liver, or lung disease?*YesNoPlease provide more details*Do you have HIV/AIDS, organ transplant or bone marrow transplant, cancer, leukemia, lymphoma, multiple sclerosis, hematopoietic stem cell or any other immune system problem?*YesNoPlease provide more details* All the information provided is correct to the best of my knowledge. I authorize the following: the release of any medical or other information with respect to this vaccine to my healthcare providers, Medicare, Medicaid, or other third-party payer, as needed, as well as to the FDA. I acknowledge that my vaccination record may be shared with federal or state agencies for registry reporting; and that the provider or pharmacist recommends that I remain in the waiting area for 20 minutes after receiving the vaccine to be observed for a reaction. If I receive curbside vaccination, I understand it is still recommended to remain nearby for 20 minutes and to quickly notify the UKHealthCare staff of any reactions. I have had the opportunity to ask questions that were answered to my satisfaction and understand the benefits and risks of the vaccine(s). I give consent for the administration of the COVID-19 vaccine(s). I have read or have had read to me the Vaccination Information Sheet (VIS) regarding the vaccine(s), and I hereby acknowledge a scheduled receipt of the COVID-19 vaccine.Please enter your initials:*CommentsThis field is for validation purposes and should be left unchanged.