COVID-19 Vaccine Consent Form_01_10_2021

COVID-19 Vaccine Consent Form

In order to receive the vaccine, you must be in the most appropriate phase of the vaccine rollout. Visit this link (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations.html) for more information at the federal level. States may have a different approach.
Vaccine Recipient Name *

First Name Middle Name Last Name
Vaccine Recipient Physical Address *

Street Address

Street Address Line 2

City State Initials

Zip Code
Date of Birth *

Month Day Year
Gender at birth *
Race *
Ethnicity *
Vaccine Recipient Phone Number *
Mother's Maiden Name *
Required for proper vaccine documentation
Primary Care Provider Name
Emergency Contact Name *
Relationship to Emergency Contact *
Phone Number of Emergency Contact *

COVID-19 Vaccine Screen Questions *

	Yes	No	Don't Know
1. Are you feeling sick today?
2. Have you ever received a dose of COVID-19 Vaccine?
3a. Have you ever had an allergic reaction to 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?
3b. Have you ever had an allergic reaction to Polysorbate?
3c. Have you ever had an allergic reaction to a previous dose of COVID-19 Vaccine? Allergic Reaction Defined: 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.
4. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?
5. 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.
6. Have you received any vaccine in the last 14 days?
7. Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19?
8. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? [note: monoclonal antibodies does not include antibiotics that you would be prescribed and filled at a pharmacy]
9. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
10. Do you have a bleeding disorder or are you taking a blood thinner?
11. Are you pregnant or breastfeeding?

COVID-19 Vaccine Manufacturer for the first dose received (do not complete if you selected "no" to #2 above.)
Required if you selected "Yes" to #2
Date of first dose (do not complete if you selected "no" to #2 above.)

Month Day Year
Required if you selected "Yes" to #2

Consent (check each box below after reading and prior to signing the form) *

	Check each box
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet (the Moderna Fact Sheet is available after clicking submit), a copy of which I was provided with this Consent Form. 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 Form.
I understand that at this time, the COVID-19 vaccine requires 2 doses given 21-28 days apart depending on the manufacturer. If this is my second dose, I will bring my vaccine card with me to be completed.
I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.
I understand that I will be receiving the vaccination at no cost to me.

The vaccine is available to anyone no matter if insured or uninsured.. Please check only one of the following. *

	Check one
If INSURED, check this box attesting to bringing in your prescription and medical insurance cards for your vaccine appointment. By selecting this, you are also authorizing the pharmacy to bill your insurance on your behalf for the immunization – understanding you will not incur any costs.
If UNINSURED, you must check this box to attest that the 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 benefit plan.

Insurance Information. (Please include BIN, PCN, ID# & GROUP #)
Medicare Patients (Especially Those Over 65) Please Ensure You Provide The New Medicare PART A/B Card. In MOST Cases This Is What We Use To Bill The Shot
Photo Of Insurance Care (front)

Cancel of
Photo Of Insurance Care (back)

Cancel of

Additionally, at this time we are only able to vaccinate NYS residents *

	Check one
I CONFIRM, that I am a New York State Resident and have a valid state ID that I will present prior to my injection.

For uninsured patients, please select at least one of the following that you will bring with you to your appointment. (This is needed in order to have your vaccine administration fee paid for by the United States Health Resources & Services Administration's COVID-19 Program.)

Military Id Social Security Number Driver's license number and state of issuance State identification number and state of issuance
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):

Clear
Date Signed

Month Day Year
Date

Pharmacy Use Only

	Vaccine	Dose	Route	Date Dose Administered	Vaccine Manufacture	Lot Number	Expiration Date	Name of Vaccine Administrator
COVID-19

Should be Empty: