GUAM

Dose 1: Vaccine

Dose 2: Vaccine

Booster: Vaccine

Not Eligible

Sorry currently you are not eligible.

Prevaccination Questionnaire

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 check in with your community navigator at AMC.

Are you feeling sick today?

Yes

No

Don't Know

Do you have a vaccine brand preference?

Note that some brands may not be available at all locations. For the most appointment options select 'Any brand available'

Any brand

Pfizer

Moderna

Johnson & Johnson

Another product

If another product Please List:

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.)

A component of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures

Yes

No

Don't Know

Polysorbate

Yes

No

Don't Know

A previous dose of COVID-19 vaccine

Yes

No

Don't Know

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

Yes

No

Don't Know

Have you received any vaccine in the last 14 days?

Yes

No

Don't Know

Last Date Vaccine

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

Yes

No

Don't Know

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

Yes

No

Don't Know

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

Yes

No

Don't Know

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

Yes

No

Don't Know

Are you pregnant or breastfeeding?

Yes

No

Don't Know

Your Demographic Information

First Name*

Last Name*

Mother's Name

What is your date of birth?*

What is your sex and race?

Why are we asking for this?

Gender*

Race*

Country of your Residence*

Your Contact Details

Phone Type

Phone Number*

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Email*

Your Guam Transit Stay

PO Box

Street Address*

Unit/Apt on street address

City*

For your stay at Guam, please provide us the info of the hotel that you're currently staying at

Hotel*

Zip*

Your Insurance Details

Testing in Guam is primarily paid for by health insurance. Do you have health insurance?*

Yes

No

Why are we asking for this information?

Insurance Provider*

Not Listed Provider

Insurance Member ID*

Insurance Group Number

Relationship to this insured

Initial *

I attest that I don't have employer-sponsered or individual healthcare coverage, Medicare, Medicaid and that no other payer will reimburse for COVID-19 testing from AMC.

Identification Type*

Identification Number*

Social Security Number

Consent Form

CONSENT FOR SERVICES:

Initial *

I have read the attached mRNA COVID-19 vaccine fact sheet. I understand the expected benefits and possible risks and side effects of the vaccines. I have voluntarily chosen to receive the vaccination and consent to the administration. I understand the possible risks to myself if I am not vaccinated. I will alert my provider of any medical conditions which may adversely affect my personal health or the effectiveness of the vaccine. I have had the opportunity to have my questions answered by American Medical Center staff.

I authorize American Medical Center staff to administer the mRNA COVID-19 vaccine to myself.

Initial*

I understand that AMC may be required to or may voluntarily disclose my health information to the physician responsible for this protocol of specific health information of people vaccinated at AMC (if applicable), my Primary Care Physician (if I have one), my insurance plan, health systems and hospitals, and/or state or federal registries, for purposes of treatment, payment or other health care operations (such as administration or quality assurance).

LOCATION

Please select a location you woud like to attend

Pick a date

Please choose one of the available dates.

Pick a time

Please choose one of the available time

Please Confirm your info and book your appointment

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Your appointment is confirmed.

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Please remember to bring your ID and your confirmation number to your appointment

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