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Vaccination Drive from MoM & Me Clinic, Sahakarnagar, Bengaluru
Vaccination Registration Form
Full Name
*
Mobile No.
*
Email Id
*
Date of Birth
*
Alternative Mobile No.
*
Aadhar No.
*
Age
*
45+
18+
Vaccination Type
*
Covishield
Covaxin
Dosage Type
*
First Dose
Second Dose
Apartment/Flat No
*
Apartment/Institution Name
*
Address
*
COWIN APP Registration Reference
Disclaimer & Confirmation
Disclaimer & Confirmation
Please note that the following people are not eligible to participate in this:
People with history of reaction to previous dose
Any kind of Immediate or delayed-onset anaphylaxis or allergic reaction to vaccines or injectable therapies, pharmaceutical products, food-items etc., in the past.
Have not completed 90 days post being infected by SARS-CoV-2.
Those not completed the Govt. prescribed gap between the two doses.
I confirm that I or any other beneficiary didn’t / do not have contraindications:
Having active symptoms of SARS-CoV-2 infection.
Have been given anti-SARS-CoV-2 monoclonal antibodies or convalescent plasma.
Acutely unwell and hospitalized (with or without intensive care) patients due to any illness.
Have not taken any dose of covid vaccination earlier.
I also give my express consent to share all the relevant information with the applicable government, government agents and external healthcare providers as and when needed for vaccination related activities.
I confirm the above and I am interested in getting vaccination done for self/dependents (as applicable) as and when available at our premises or otherwise, through our select partners. I also confirm that all the information provided by myself above is true and nothing has been concealed. I further understand that this service/activity of vaccination provided by Mom & Me is only to facilitate vaccination and the centre will not be held responsible for any side effects of the vaccines whatsoever. I further undertake to keep Mom & Me, its employees, directors, successors and assignees fully harmless, indemnified and compensated from and against any and all claims, actions, losses, damages which the Centre may face, sustain or suffer with respect to the above mentioned vaccination given to me/dependents.
*
fields are Mandatory
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