North- 0213-6648237-9, Clifton- 021 35862937-9
COVID19 VACCINE FORM
Your Name *
Your Gender *
Male
Female
Verification Document Type *
CNIC
Passport
CNIC *
Note:
Only digits without ' - ' OR Space
Mobile Number *
Note:
Only digits without ' - ' OR Space e.g 03212568027
Email ID *
Date Of Birth *
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Have you ever been vaccinated for COVID-19 in the last 90 days? *
Yes
No
Have you received any other vaccine in the last 10-14 days? *
Yes
No
Do you have any allergies to food products? *
Yes
No
Do you have any allergies to medical products? *
Yes
No
Are you suffering from any active and severe medical disease in the last 4 weeks? *
Yes
No
Have you taken steroids over the last 6 weeks? *
Yes
No
Have you ever tested positive for COVID-19? *
Yes
No
Are you on any immunosuppressive agents for autoimmune diseases such as rheumatoid arthritis? *
Yes
No
Do you have cancer and are on active chemotherapy or immunosuppressants? *
Yes
No
Received organ or bone marrow transplant in the 3 months or if still on active immunosuppression? *
Yes
No
Agreement
I hereby declare that all the given information are accurate.
I have reviewed my answers to the questions above. If I experience any adverse reactions after leaving, I will notify my primary care provider.
I understand the benefits and risks of the vaccine.
Please answer *
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