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AFC LaPorte

8850 Spencer Highway

Suite 100

LaPorte , TX 77571

281-946-9980

En Español

Welcome to AFC Urgent Care!

Hello, thank you for signing up! Please answer all questions below to better assist you when you come in for your visit. If you have any question, please call before booking your appointment.
We thank you in advance for your understanding and cooperation.

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1. Are you feeling sick today?

2. Have you ever received a dose of COVID-19 vaccine?

3. Have you ever had an allergic reaction to: (This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen* or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.)

A. A component of a COVID-19 vaccine including either of the following: -Polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures -Polysorbate, which is found in some vaccines, film coated tablets, and intravenous steroids.

B. A previous dose of COVID-19 vaccine.

C. A vaccine or injectable therapy that contains multiple components, one of which is a COVID-19 vaccine component, but it is not known which component elicited the immediate reaction.

4. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication? (This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen* or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.)

5. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a component of COVID-19 vaccine or any vaccine or injectable medication? This would include food, pet, venom, environmental, or oral medication allergies.

6. Have you received any vaccine in the last 14 days?

7. Have you ever had a positive test for COVID-19 or ahs a doctor ever told you that you had COVID-19?

8. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?

9. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?

10. Do you have a bleeding disorder or are you taking a blood thinner?

11. Do you have a history of or a risk factor for blood clotting disorder?

12. Are you pregnant or breastfeeding?

13. Do you have dermal fillers?

The following questions will help us determine if there is any reason you should not get the COVID-19 vaccine today. If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions may be asked. If a question is not clear, please ask your healthcare provider to explain it.

AFC LaPorte

8850 Spencer Highway

Suite 100

LaPorte , TX 77571

281-946-9980

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