SDOC COVID-19 Consent Form

SDOC COVID-19 Vaccine POD Vaccine Consent Form

In order to receive the vaccine, you MUST be in the most appropriate phase of the vaccine rollout per Osceola-DOH guidelines .
* PLEASE READ BEFORE COMPLETING FORM * * YOU MUST BRING CDC VACCINE CARD TO 2nd SHOT * You must complete this form prior to 1st AND 2nd Dose * Those patients that cannot return to original site can receive 2nd dose at: Prescriptions Unlimited 2521 13th Street, St. Cloud, FL 34769

For this specific vaccine POD, to qualify you MUST fulfill the following criteria: - 12 and over (12 and up must be accompanied by parent/guardian); or, - Parent of SDOC student; or, - SDOC employee; and, - provide your student/employee ID, Drivers License and one of the two: (1) Social Security Card OR (2) insurance card at the vaccination site. * We will be providing ONLY Pfizer COVID-19 Vaccine
Is patient to be vaccinated 12 years or older?*
To qualify you MUST be 12 and over and accompanied by parent/guardian if under 18 years of age. Parent ID required.
Is this your first or second dose?*

First DoseSecond Dose
Vaccine Recipient Name*

First NameMiddle NameLast Name
Where do you want your vaccine?*
Please be sure to Select the Date that matches your Location.
Drive Through Appointment Time*
Person Completing form (if not patient)
Name, Contact #, Company (Provider, HHA, etc)
Email*
example@example.com
Vaccine Recipient Physical Address*

Street Address

Street Address Line 2

CityState Initials

Postal / Zip Code
Date of Birth*

MonthDayYear
Gender at birth*
Race*
Ethnicity*
Vaccine Recipient Phone Number*
Do you have insurance?*

YesNo
Insurance Company
Medicaid ID, Insurance ID # or Social Security Number*
Must provide this field accurately 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*

	Yes	No
1. Are you feeling sick today? Se siente enfermo/a hoy?
2. Have you ever received a dose of COVID-19 Vaccine? Recivio alguna vez una dosis de la vacuna COVID-19?
4. Have you ever had an allergic reaction to a vaccine (other than COVID-19 vaccine) or an injectable medication? Ha tenido alguna vez una reaccion alergica a una vacuna (algo que no sea un componente de la vacuna COVID 19) o medicacion inyectable?
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? Ha tenido alguna vez una reccion alergica grave ( por ejemplo, anafilaxis) o algo que no sea un componente a la vacuna COVID-19, polisorbato o cualquier vacuna o medicacion injectable? Ha recibido alguan vacuna en los ultimos 14 dias? This would include food, pet, environmental, or oral medication allergies. Esto incluiria alergias algun alimento, mascostas, medioambiente, o orales.
7. Have you had a POSITIVE test for COVID-19 in the previous 10 days? Ha tenido una prueba POSITIVA al COVID-19 en los ultimos 10 dias?
8. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? Ha tenido terapia pasiva de anticuerpos( anticuerpos monoclonales o suero convalecedor) como tratamiento para cubierta en contra el COVID 19?
[note: monoclonal antibodies does not include antibiotics that you would be prescribed and filled at a pharmacy][NOTA: Los anticuerpos monoclonales no incluyen antibioticos que se le prescribirian y se le lennarian en una farmacia]
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? Tiene un sistema inmunologico debilitado causado por algo como infeccion por HIV o Cancer o toma drogas o terapias inmunisupresoras?
10. Do you have a bleeding disorder or are you taking a blood thinner? Tiene usted un trastorno sangrante o esta tomando un anticoagulante?
11. Are you pregnant or breastfeeding? Esta usted embarazada o amamantando?

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 Pfizer 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 21-42 days apart. 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.
I certify that I am: (a) the patient and at least 12 years of age; (b) the legal guardian of the patient and confirm that the patient is at least 12 years of age; or (c) legally authorized to consent for vaccination for the patient named above. Further, I hereby give my consent to Prescriptions Unlimited to administer the COVID-19 vaccine. • I understand that this product has not been approved or licensed by FDA, but has been authorized for emergency use by FDA, under an EUA to prevent Coronavirus Disease 2019 (COVID-19) for use in individuals either 12 years of age or older or 18 years of age and older; and the emergency use of this product is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of the medical product under Section 564(b)(1) of the FD&C Act unless the declaration is terminated or authorization revoked sooner.

Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):

Clear
Date Signed*

MonthDayYear
Date
Should be Empty:

SDOC COVID-19 Vaccine POD Vaccine Consent Form

* PLEASE READ BEFORE COMPLETING FORM * * YOU MUST BRING CDC VACCINE CARD TO 2nd SHOT * You must complete this form prior to 1st AND 2nd Dose * Those patients that cannot return to original site can receive 2nd dose at: Prescriptions Unlimited 2521 13th Street, St. Cloud, FL 34769