COVID-19 Pre-Vaccination Checklist Template

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COVID-19 vaccines are in high demand and many healthcare professionals are offering first doses, second doses, and boosters. The Covid-19 Pre-Vaccination Checklist from Formsite simplifies data collection for each vaccine recipient to ensure patient safety and confidentiality regarding the COVID-19 vaccine. Protect yourself, the healthcare providers you work with, and your practice from liability and keep patients safe with this quick and easy to use coronavirus screening checklist.

This sample pre vaccination pre-vaccination checklist gathers vital information such as patient name, date of birth, contact information, whether the potential patient has received a first or second vaccine dose, as well as which type of previous dose they received. It also includes form fields that gather information about contraindications including anaphylaxis or any history of severe allergic reaction or side effects to immunizations, as well as current medicines, any immunosuppressive drugs or therapies, whether or not the individual feels sick today, or has a bleeding disorder or takes a blood thinner. There’s even a question to cover the possibility of reactions to polyethylene glycol (PEG) or polysorbate.

Tailor the form to gather any additional information you need, then embed it on your website, email the link, or post it to social media for easy viewing. No coding necessary! Mobile friendly, this HIPAA compliant screening tool minimizes errors and follows CDC and local health department best practices in gathering and securely storing pertinent patient vaccine information.

All form data can be securely downloaded and used in other software applications, too.

Pre Vaccine Checklist Form

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COVID-19 Pre-Vaccination Checklist

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