DR. ZIAUDDIN HOSPITAL || COVID VACCINE

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 *

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

Please answer * + =

Agreement