Click the link below to complete a questionnaire for the Gwinnett COVID-19 Vaccination:

Complete Questionnaire

Gwinnett COVID-19 Vaccination Questionnaire

WELCOME!
This form is a preliminary health screening for those who are interested in receiving a vaccination. Please note that this registration is open to the first 100 people who apply. All registrars after the initial 100 will be placed on a waiting list.
Personal Information
Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code
Phone*
Email*
Enter Email Confirm Email
Date of Birth*
Gender*
Race*
Ethnicity*
Gwinnett Vaccination Pre-Screening Questions
If your response to any of the below statements are Yes, you are not eligible for vaccination.
1. Have you ever had a life threatening allergic reaction after a dose of any vaccine or injectable medication or any immediate allergic reaction of any severity to a previous COVID-19 vaccine or any of its components (including polysorbate)?*
2. Have you had a vaccine within the past 14 days and will NOT receive another vaccine within the next 14 days?*
3. Are you currently under isolation (infected with COVID-19), nor under quarantine, (exposed to someone with COVID-19)?*
4. Are you currently moderately or severely ill?*
5. Have you received monoclonal antibody therapy or convalescent plasma for COVID-19 treatment in the past 90 days?*
6. Do you have a severe (life threatening) allergy to any component of this vaccine as detailed in the Emergency Use Authorization?*
Unfortunately, at this time, we are not able to complete your application for COVID-19 Vaccination Pre-Screening at this site. Please check with your local health department or physician for guidance on receiving COVID-19 vaccinations.

COVID Vaccination

Click the link below to complete a questionnaire for the Gwinnett COVID-19 Vaccination:

Gwinnett COVID-19 Vaccination Questionnaire

WELCOME!

Personal Information

Gwinnett Vaccination Pre-Screening Questions

BEREAN GWINNETT CHURCH