First Name *Surname *Phone *Email Address *GenderMaleFemaleDate Of Birth *Street AddressStateCountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaAustraliaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCabo VerdeCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGuernseyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSaint HelenaSaint Pierre & MiquelonSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUS Minor Outlying IslandsUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabweInsurance CompanyInsurance IDYou MRN in HMC if availableWhich vaccine are you planning to receive? *Yellow FeverHepatitisMeningitisTyphoidHPVPolioTetanusOtherDo you already have a vaccination yellow card? *YesNoHave you ever had an allergic reaction to a vaccine? *YesNoDo you have any ongoing immunocompromised conditions? *YesNoIncluding Chemotherapy, Radiotherapy, Hip infection, etcIf Yes, (Please specify)Are you currently experiencing any ongoing fever or acute illness? *YesNoAre you pregnant or breastfeeding? *YesNoHave you received any other vaccines or blood products recently ? *YesNoIf Yes, (Please specify)Consent *Yes, I consent to receiving the vaccine and confirm that the information provided is accurate. ➢ Thank you for taking the time to complete this form. Your commitment to your health is important to us!Important Information About Your Vaccination Appointment Dear Clients, Thank you for trusting our clinic for your immunization needs. Here’s what you need to know before your vaccination: 1. Please inform us of any previous allergic reactions to vaccines or medications, as well as any ongoing illnesses that may affect your vaccination. 2. Stay at the clinic for at least 30 minutes after receiving the vaccine for observation. 3. Common Side Effects include: - Pain or swelling at the injection site - Mild fever - Fatigue or tiredness 4. Please contact us or seek immediate medical attention if you experience the following warning signs: - Difficulty breathing or swelling of the face/throat - High fever (over 101°F or 38.3°C) - Severe headache 5. After Your Vaccination: Stay hydrated, rest, and you may take acetaminophen or ibuprofen for discomfort, unless advised otherwise. Your health and safety are our top priorities! Feel free to ask any questions during your visit. Warm regards,HMC Immunization Clinic Submit
