COVID-19 Vaccine Consent Form

  • COVID-19 Vaccine Consent Form

  • Date of Birth*
     - -
  • Gender*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Ethnicity
  • Hispanic, Latino, or Spanish*
  • Format: (000) 000-0000.
  • Check which box(es) describes you:*

  • Past Medical History

  • Are you feeling sick today?*
  • Have you already received a COVID 19 Vaccine?*
  • If yes, which vaccine product?
  • Date of 1st COVID-19 Vaccine
     - -
  • Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something? For example, a reaction for which you were treated with epinephrine or EpiPen®, or for which you had to go to the hospital?*
  • Was the severe reaction to any vaccine or injectable medication?*
  • Do you carry an EpiPen® (or its equivalent)?*
  • Are you allergic to polysorbate or polyethylene glycol or any components of the vaccine? (Powder laxative)*
  • Do you have a moderate or severe weakened immune system caused by something such as cancer, HIV infection, organ transplant, stem cell transplant or a similar condition or do you take immunosuppressive drugs or therapies?*
  • Do you have a history of Guillian-Barre' syndrome?
  • Have you had myocarditis (inflammation of the heart muscle) or pericarditis (inflammation of the lining of the heart)?
  • Have you had a positive test for COVID-19 or have you been diagnosed with COVID-19 in the last 90 days?*
  • If yes, when?
     - -
  • Have you had immune globulin, monoclonal antibodies, convalescent serum, or a blood transfusion in the past 90 days (3 months)?*
  • In the past 2-14 days have you experienced fever or chills, cough, shortness of breath, fatigue, muscle/ body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea?*
  • In the past 2-14 days are you aware of being exposed to someone who tested positive for COVID-19?*
  • Are you pregnant or planning to be pregnant in the next 3 months?
  • Are you breastfeeding?
  • Have you received another vaccine or injection in the past 14 days?*
  • Do you have a bleeding disorder or are you taking a blood thinner?*

  • Consent to Immunize

  • I reviewed a copy of the Vaccination FDA Emergency Use Authorization (EUA) and have had the opportunity to ask questions about the risks and benefits of this vaccination.*

  • Moderna COVID-19 Vaccine EUA

    https://www.fda.gov/media/144638/download

  • Pfizer COVID-19 Vaccine EUA for 12 Years of Age and Older

    https://www.fda.gov/media/153716/download

  • Pfizer COVID -19 Vaccine EUA for 5 Through 11 Years of Age

    https://www.fda.gov/media/153717/download

  • J&J Janssen COVID-19 Vaccine EUA

    https://www.fda.gov/media/146305/download

  • Novavax COVID-19 Vaccine EUA

    https://www.fda.gov/media/159898/download

  • I understand common side effects may include injection site redness, swelling, or pain, swelling of lymph nodes in arm of injection, aches or muscle pain, joint pain, fatigue, headache, shivering or chills, fever, gastrointestinal symptoms, malaise, and that the benefits include disease prevention.*
  • I am aware of reports of rare Thrombosis with Thrombocytopenia 1-2 weeks following the Janssen vaccine. I am aware of an increased risk of Guillain-Barre’ syndrome 42 days following vaccination with the Janssen or Novavax vaccine.
  • I understand that it is recommended that I stay on location 15-30 minutes following the injection.*
  • This vaccination record will be reported to the Texas Department of Health Immunization Tracking Service and primary healthcare providers.*
  • I consent for the vaccination to be administered to me and for the immunizer to initiate the emergency medical plan if necessary due a reaction to the vaccination.*

  • I am aware of the potential risks and side effects of the vaccine as described in the literature as well as the risk of the disease it prevents. I hereby waive any liability towards Valmed Home Health & Pharmacy Solutions and/or its administering employee of potential adverse effects associated with administration of the vaccine. I authorize the release of any medical or other information necessary to process the claim and I hereby assign all insurance, Medicare, Medicaid and other third-party payors' benefits for services rendered. I have been offered the HIPAA Privacy Policy.

  • Date*
     / /
  • Insurance Information (Please provide a copy of your insurance cards at the vaccine appointment.)

  • We encourage you to download the V-Safe tool that uses text messaging and web surveys to provide personalized health check-ins after you receive a COVID-19 vaccine.  Through V-Safe, you can quickly tell CDC if you have any side effects after getting the vaccine.  V-Safe will also remind you to get your second COVID-19 vaccine.

  •  
  • Should be Empty: