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COVID-19 Vaccination Registration

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COVID-19 Vaccination Registration Form


Medical History

Are you suffering with any of the symptoms – Fever, cold, cough, sore throat, malaise, headache and other?

If yes, consult your doctor

Do you have active symptoms of COVID-19 infection (lab confirmed)?

If yes, deferral for 3 months after recovery

Did you have any serious allergic reaction (which needed emergency medical attention) to a previous dose of COVID-19 vaccine?

If yes, permanent deferral

Did you have either immediate or delayed-onset serious allergic reaction (which needed emergency medical attention) to other vaccines or injectable therapies, pharmaceutical products, food-items etc.?

If yes, permanent deferral

Do you have history of being unwell and hospitalized (with or without intensive care) due to any illness?

If yes, deferral for 4-8 weeks after recovery

Do you have history of bleeding / coagulation disorder like 'haemophilia'?

If yes, consult your doctor

Are you on any regular medication?

If yes, continue the same medication

Have you been immunized or vaccinated in the recent past with any other vaccine?

If yes, deferral for 2 week

Did you take COVID-19 vaccination?

If yes, the second dose schedule as of now:
  • Covishield 12–16 weeks
  • Covaxin is 4–6 weeks after the first dose
For women

Are you pregnant or not sure of being pregnant?

If yes, deferral till delivery / confirmation

Are you breast feeding your child?

Eligible for vaccination

Are you in menstrual periods now?

Eligible for vaccination
Vaccination beneficiary’s consent

I understand that:

  1. Vaccination is a totally voluntary and a willful act
  2. I accept the risk associated with the procedure
  3. My personal/medical details shall remain confidential with Star Hospitals

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