Josefs Raleigh

Josefs Raleigh

2100 New Bern Ave Raleigh, NC
COVID-19 Vaccine Consent Form
Please enter your appointment date and time. *

Month Day Year
Date
Hour Minutes AM/PM Option
Vaccine Recipient Name *

First Name Last Name
Vaccine Recipient Physical Address *

Street Address

Street Address Line 2

City State Initials

Postal / Zip Code
Date of Birth *

Month Day Year
Please enter your date of birth
Vaccine Recipient Phone Number *
Please enter your phone number
Email *
example@example.com
Gender *
Race:
Please Select
Ethnicity:
Primary Care Provider Name
Emergency Contact Name *
Relationship to Emergency Contact *
Phone Number of Emergency Contact *
Enter Emergency Contact Phone Number
1. Are you feeling sick today? *

Yes No
2. Have you ever received a dose of Covid19 Vaccine? *

Yes No
COVID-19 Vaccine Manufacturer for the first dose received?
Required if you selected "Yes" to #2
Date of first dose?

Month Day Year
3. Have you ever had an allergic reaction to any of the following? (Select all that apply)

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 Polysorbate A previous dose of Covid-19 Vaccine None of the above
4. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication? *

Yes No
5. Have you ever had a severe allergic reaction to something other than a component of COVID-19 vaccine, polysorbate, or any vaccine or injectable medication? *

Yes No
6. Have you received any vaccine in the last 14 days? *

Yes No
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? *

Yes No
8. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as a treatment for COVID-19? (This does not include antibiotics that would be prescribed to you and filled at a pharmacy) *

Yes No
9. Do you have a weakened immune system caused by something such as HIV infection, cancer, or do you use immunosuppressive drugs or therapies? *

Yes No
10. Do you have a bleeding disorder or are you taking a blood thinner? *

Yes No
11. Are you pregnant or breastfeeding? *

Yes No N/A

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 COVID-19 Vaccine is available to anyone no matter if insured or uninsured. Please select if you have do or do not have insurance. *

I have insurance I do not have insurance
INSURED Patient Consent: Please indicate your consent attesting that you will bring your prescription and medical insurance cards for your vaccine appointment. You also consent that you authorize the pharmacy to bill your insurance on your behalf for the immunization - understanding there will be no cost to you.

I, the undersigned, consent to the terms indicated.
UNINSURED Patient Consent: Please indicate your consent attesting that the following information is accurate. I do not have any insurance, including but not limited to, Medicare, Medicaid, or any other private or government-funded benefit plan.

I, the undersigned, consent that the information provided is true and accurate.
For uninsured patients, please select at least one 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
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):

If unable to sign, signature maybe obtained on the day you receive your vaccine. Clear
Date Signed

Month Day Year
Should be Empty:

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Josefs Raleigh

COVID-19 Vaccine Consent Form