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.
Do you qualify to receive the COVID-19 Vaccine as per FL State Mandate and Guidance for Phase 1 & Phase 2 vaccination?
No (Fill out this form and join our waitlist/standby). We shall contact you.
Type of Vaccine that you would like to receive:
Moderna Covid-19 Vaccine
Pfizer Covid-19 Vaccine (Not in stock)
Johnson & Johnson’s Single Dose Covid-19 Vaccine (Approved by CDC & FDA)
Select an appointment time
Vaccine Recipient Name
Vaccine Recipient Physical Address
Date of Birth
Gender at Birth
Vaccine Recipient Phone Number
Social Security No. (For claims)
Hispanic or Latino
Not Hispanic or Latino
American Indian or Alaska Native
Black or African American
Native Hawaiian or Other Pacific Islander
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
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
3c. Have you ever had an allergic reaction to a previous dose of COVID-19 Vaccine?
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?
Which arm would you like to get the injection on
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 Vaccine Fact Sheets are available on our website www.duvalpharmacy.com), 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 the Johnson & Johnson's Vaccine is a single dose vaccine and the Pfizer's & Moderna's 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.
The vaccine is available to anyone no matter if insured or uninsured. Please check only one of the following.
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.
Please Upload Insurance Card
Drag and drop files here
Choose a file
For uninsured patients, please select at least two of the following that you will bring with you to your appointment.
Social Security Number
State identification number and state of issuance
Driver's license number and state of issuance
Please Upload Supporting Uninsured Document
Drag and drop files here
Choose a file
Signature of Person to Receive Vaccine & EUA/VIS (or Parent/Guardian if Patient is less than 18 years)
Immunizer Pharmacist Name
First and Last Name
Manufacturer Date: 03/17/2021
Immunizer Pharmacist Signature
Submit Consent Form (required)
Should be Empty: