COVID Vaccine Consent Form

COVID-19 Vaccine Consent Form

* Please fill out the required details below
Section I. Appointment Scheduler
Please pick a day and time for your vaccination*
Section II. Personal Information
Patient's Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Age:*
Address:*

Street Address Line 2

You must be a resident of GA
State*
Phone Number:*
Email*
Gender:*

MF
Please choose which Covid-19 vaccine you would like to receive:*

SPIKEVAX by Moderna (Updated Covid-19 Vaccine for 2023-24)
Race:*

African AmericanAmerican IndianAsianCaucasian/WhiteHispanic or LatinoNative Hawaiian/Other Pacific IslanderPrefer not to answerOther
What is Mother's Maiden First and Last Name?*
Section III. 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 have a history of allergic reaction to any of these ingredients listed below? Each 0.5 mL dose of SPIKEVAX (2023-2024 Formula) contains 50 mcg nucleoside-modified messenger RNA (mRNA) encoding the pre-fusion stabilized Spike glycoprotein (S) of the SARS-CoV-2 Omicron variant lineage XBB.1.5. Each dose also contains the following ingredients: a total lipid content of 1.01 mg (SM-102, polyethylene glycol [PEG] 2000 dimyristoyl glycerol [DMG], cholesterol, and 1,2-distearoyl-sn-glycero-3-phosphocholine [DSPC]), 0.25 mg tromethamine, 1.2 mg tromethamine hydrochloride, 0.021 mg acetic acid, 0.10 mg sodium acetate trihydrate, and 43.5 mg sucrose.
2. Do you have a history of severe allergic reactions, such as an immediate-onset anaphylaxis to medications, foods, or any vaccines (eggs, gelatin, thimerosal, neomycin, gentamicin, latex, aluminum, preservatives, baker's yeast, etc.)?
3. Have you ever been diagnosed with Guillain-Barre’ syndrome or other neurological disorder related to a vaccine?
6. Have you received any antibody treatment for COVID-19 in the last 90 days?

Please specify the allergy from Q2:
Section IV. Signatures

I have read, or have had read to me, the written information regarding the vaccine(s) being administered. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s) being administered and have received a copy of a current FACT SHEET OR Vaccine Information Sheet. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless West End Pharmacy, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s). I certify that I am at least 18 years old and hereby give my consent to the pharmacists of this West End Pharamcy to administer the vaccine(s). If under 18 years old signature by parent or guardian is required.
I agree to wait near the vaccination location for approximately 15 minutes for observation by the pharmacist.

FACT SHEET FOR SPIKEVAX 2023-2024 FORMULA
Signature of Person to Receive Vaccine & EUA/VIS (or Signature of Parent/Guardian if Patient is < 18 yo)*

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I have received a copy of the notice of 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:*

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Pharmacist Use Only:

Vaccine		Mnf.	LOT	Exp Date	Dose	Site of Injection	Date of Fact sheet	RPH Initials
Covid-19						LD RD

Vaccine Card ____ 1st Dose ____ Booster Dose ____

GRITS ___ 2nd Dose ____ Additional Dose ____

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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COVID-19 Vaccine Consent Form