COVID Vaccine Consent Form

Please enter your Date of Birth *

Date

Your Profession:

Health care personnel I am a frontline essential worker Other essential worker Other

What dose of COVID vaccine will this be? *

First Second

Have you received COVID-19 monoclonal antibodies or convalescent plasma in the last 90 days? *

Yes No

Have you received any other vaccine in the past 14 days? *

Yes No

You are not eligible

Section I. Personal Information

Patient First Name *

Patient Last Name *

Gender: *

Male Female

Phone Number: *

Email *

Confirmation Email example@example.com

Address: *

Street Address

Street Address Line 2

State

Zip Code

City *

Primary Care Doctor: *

Doctor City/State: *

Please enter any and all drug or food allergies:

Section II. Questionnaire for Immunization

Please select the correct option below: *

	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: 1. Do you feel sick today?
2. Have you ever had a serious or life-threatening allergic reaction (hives, difficulty breathing) to any vaccine or shot ?
3. Do you carry an EpiPen?
4. Have you received COVID-19 monoclonal antibodies or convalescent plasma in the last 90 days? YOU ARE NOT ELIGIBLE IF THIS ANSWER IS YES!
5. Have you had any OTHER vaccines in the past 14 days? PLEASE WAIT 14 DAYS AFTER ANY OTHER IMMUNIZATION BEFORE GETTING COVID VACCINE!
6.Do yo have a bleeding disorder or are you taking blood thinners?
7. Do you have a weakened immune system caused by something such a HIV infection or cancer or do yo take immunosuppressive drugs or therapies?
8. Are you pregnant or breasfeeding
9. 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?
10. Have you ever had an allergic reaction to Polysorbate?
11. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?
12. 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

Section III. Signatures

In an attempt to reduce paper waste, all legally required documents must be downloaded here. Very limited copies will be available on clinic day.

Click this to download the Emergency Use Authorization for the Moderna Vaccine.

Click this to download the Notice of Privacy Practices

Click this to download the CDC vSafe app flyer

I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA), a copy of which I was provided with this registration.

I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.

I certify that I have received, read, and understand the Emergency Use Authorization.

I certifty that I have received the Notice of Privacy Practices.

I certify that I have received the CDC vSafe informational flyer.

Please type your full name in the box below. You agree your typed full name represents your electronic signature is the legal equivalent of your manual signature on this form.

Type Your Full Name as Electronic Signature *

Insurance Billing for the Administration of the Vaccine

I authorize the pharmacy to bill my insurance on my behalf for the immunization

If uninsured, you must check the box below to attest that 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 health benefit plan

In order to have your vaccine administration fee paid for by the United States Health Resources & Services Administration's COVID-19 Program for uninsured patients, please select to provide one of the following: *

Social Security Number State identification number and state of issuance Driver's license number and state of issuance

Social Security Number *

State identification number and state of issuance *

Driver's license number and state of issuance *

Section IV. Appointment Confirmation

**Vaccine supply is limited. Please keep your appointment.**

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 in the future.

Choose Your Appointment Time: *

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.

COVID Vaccine UNIVERSAL FORM

Section I. Personal Information

Section II. Questionnaire for Immunization

Section III. Signatures

Section IV. Appointment Confirmation