Vaccination Drive from MoM & Me Clinic, Sahakarnagar, Bengaluru

Vaccination Registration Form

Disclaimer & Confirmation
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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.
* Mandatory fields