COVID Vaccine Consent Form

Bivalent Booster shots are available 2 months from your previous Covid-19 vaccination.

Booster shots are now on a walk-in basis, Monday - Friday, 10-4:30pm.

Section I. Personal Information

Patient's Full Name

First NameMiddle NameLast Name

Date of Birth:

Gender:

Mother's Maiden Name

Phone Number:

Address:

Street Address Line 2

Race/Ethnicity:

Primary Care Doctor

Doctor Phone Number

Area CodePhone Number

Are you one of the following?

What dose of COVID-19 vaccine will this be?

When did you receive your last dose?

Date

Section II. Questionnaire for Immunization

Please select the correct option below:

Rows	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 received COVID-19 monoclonal antibodies or convalescent plasma in the last 90 days?
Have you ever had a serious reaction or fainted after receiving any vaccination?
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?

List Allergies:

My preferred vaccine is:

Type of Insurance Coverage:

Medicare Info:

Insurance Info:

Driver's License/State ID/SSN:

**Vaccine supply is limited. Please keep your appointment or call if you need to cancel or change it. Additionally, due to vaccine requirements; we may call you to see if you can come earlier, later or to a nearby location. If you miss an appointment, no doses will be held to guarantee your dose.**

Section IV. Signature

I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (https://www.modernatx.com/covid19vaccine-eua/eua-fact-sheet-recipients.pdf) 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 and Date

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.

Date Added

Date

County of Residence

Notes 1

Notes 2

COVID Vaccine Consent Form

Imported Information