COVID Vaccine Consent Form

If you have remaining questions, please call us at 515-964-8550.

You are signing up for a TWO DOSE vaccine (Moderna). This vaccine is currently indicated for individuals age 18 year and older.

Section I. Personal Information

Patient's Full Name: *

First Name Ml Last Name

Patient's Date of Birth: *

Age: *

Phone Number: *

Email: *

Gender: *

Male Female

Parent/Guardian Full Name: (provide for anyone under 18 yrs)

First Name Ml Last Name

Ethnicity: *

Hispanic or Latino Non Hispanic/Latino Unknown Prefer not to answer

Race: *

African American American Indian Asian Caucasian Native Hawaiian/Other Pacific Islander Prefer not to answer

Address: *

Street Address Line 2

Primary Care Doctor: *

Doctor City/State: *

Are you one of the following? *

Healthcare Worker Person age 65 yrs or older First Responder (police, fire, child welfare social worker) PK-12 School staff, early childhood educator or childcare worker Person with chronic condition(s) Resident of a care facility or other group setting No, I am not any of the above

Please specify chronic condition:

https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html?utm_medium=email&utm_source=govdelivery

What dose of COVID-19 vaccine will this be? *

First Dose Second Dose

When did you receive your first dose? *

Date

Section II. Questionnaire for Immunization

Please select the correct option below: *

	Yes	No	Don't know or N/A
COVID-19 Screening Questions: In the past two weeks, have you tested positive for COVID-19 or are you currently being monitored for COVID-19?
In the past two weeks, have you had a known exposure with anyone who tested positive for COVID-19?
Have you had a new onset of fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, nausea, vomiting, or diarrhea?
Questionnaire for Immunization: Do you feel sick today?
Do you have an allergy to medications, foods, or any vaccines (eggs, gelatin, thimerosal, neomycin, gentamicin, latex, aluminum, preservatives, baker's yeast, etc.)?
Do you carry an EpiPen?
Have you been diagnosed with or suspected of having covid in the last 90 days?
If yes to the above question, did you receive medications, plasma or other treatment?
Have you ever had a serious reaction or fainted after receiving any vaccination?
Have you received any other vaccinations in the last 14 days?
Have you ever had a seizure, brain disorder, or Guillain-Barre Syndrome?
For women: Are you pregnant or are you planning on becoming pregnant during the next month?

Please specify the allergy from Q2:

Section III. Appointment Scheduler

**Please keep your appointment or call if you need to cancel or change it. If you miss an appointment, no doses will be held to guarantee your dose.**

Please pick a day and time for your vaccination *

Section IV. Signatures

I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA), a copy of which I was provided with this Consent and Release. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent and Release.

Signature of Person to Receive Vaccine & EUA/VIS (or Signature of Parent/Guardian if Patient is < 18 yo) *

Clear

I have received a copy of the notice of Privacy Practices. I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.

Signature of Acknowledgment of Notice of Privacy Practices: *

Clear

Medicare Part B Number: *

Please enter your Medicare Part B number even if you have Medicare Advantage or other insurance.

Please take or upload pictures of front & back of insurance card for billing purposes

Browse Files

I authorize the pharmacy to bill my insurance on my behalf for the immunization and the information provided is true and accurate.

If uninsured, you must check the box below to attest that the following information is true and accurate:

I do not have any insurance, including but not limited to Medicare, Medicaid or any other private or government-funded health benefit plan

In order to have your vaccine administration fee paid for by the United States Health Resources & Services Administration's COVID-19 Program for uninsured patients, please select to provide one of the following: *

Social Security Number State identification number and state of issuance Driver's license number and state of issuance

Social Security Number: *

State identification number and state of issuance: *

Driver's license number and state of issuance: *

By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.

COVID Vaccine Consent Form - Ankeny