COVID Vaccine Consent Form

COVID Vaccine Consent Form

* Please fill out the required details below
Section I. Personal Information
Patient's Full Name:*

First NameMlLast Name
Date of Birth:*

MonthDayYear
Age:*
Phone Number:*
Email:*
Gender:*

MaleFemaleN/A
Ethnicity:*

Hispanic or LatinoNon Hispanic/LatinoUnknownPrefer not to answer
Race:*

African AmericanAmerican IndianAsianCaucasianNative Hawaiian/Other Pacific IslanderPrefer not to answerOther
Address:*

Street Address Line 2
To Better Help us meet your needs, please select from the options below that best describes you regarding your COVID-19 vaccination:

This is my first vaccination.I have a preference on the vaccination I receive.My preference is Moderna.My preference is Pfizer.I have received my first dose of Pfizer within the last 2 weeks and need my second dose.I have received my first dose of Moderna within the last 3 weeks and need my second dose.I have received my first and second dose of the COVID vaccination and would like my booster.
Primary Care Doctor Name | Phone Number*
FOR BOOSTERS ONLY: Are you one of the following?*

Have you received two doses of Pfizer of Moderna?Are you 65 years or older?Are you 50-64 with an underlying health medical condition?Do you live in a Long Term Care Facility?Are you 18-64 years old and at high risk of severe COVID-19?Are you 18 to 64 years old and at high risk because of where you live or work?Are you 18-49 with an underlying medical condition?Received the Johnson & Johnson vaccine for your initial dose?Are you 12-17 years old?Are you 5-11 years old?
MODERNA: What was the date of your second dose?

MonthDayYear
Date
PFIZER: What was the date of your second dose?

MonthDayYear
Date
JOHNSON & JOHNSON: What was the date of your vaccination?

MonthDayYear
Date
FOR 1st VACCINATION ONLY: Are you one of the following

Are you 12 years or older?
FOR 2ND VACCINATION ONLY: Which one did you receive for your 1st vaccination?

ModernaPfizer

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: 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?

Please specify the allergy from Q2:
Section III. Appointment and Signatures
**Vaccine supply is pre-planned for each day for scheduled appointments. Please keep your appointment or call if you need to cancel or change as soon as possible so we can fill your appointment slot. This also prevents waste the vaccination. Additionally, due to vaccine requirements; If you miss an appointment, no doses will be held to guarantee your dose the day of your appointment.**
Section III. Signatures

I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) (Moderna EUA), 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 of Person to Receive Vaccine & EUA/VIS (or Signature of Parent/Guardian if Patient is < 18 yo)*

Clear
I have received a copy of the notice of Privacy Practices. (Click the Purple Link to open Privacy Practices) 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.
Signature of Acknowledgment of Notice of Privacy Practices:*

Clear
Please upload a copy of front & back of your insurance card for billing purposes. If you are having difficulties doing so, please call the pharmacy for assistance. Do not schedule an appointment for non COVID vaccinations prior to uploading insurance information. Please do not skip this option, as this helps keep us on time for appointments.

Browse Files

Cancelof
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
Social Security Number/You may give this to us at the time of check in if you are on an unsecure browser.*
Please provide the State identification number and state of issuance*
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 NumberState identification number and state of issuanceDriver's license number and state of issuance
Driver's license number and state of issuance*
If you plan on getting more than a COVID BOOSTER please select below what other vaccinations you need. 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.
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