COVID-19 Vaccine Consent Form Vaccine Clinic
In order to receive the vaccine, you must be in the most appropriate phase of the vaccine rollout. Visit this link (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations.html) for more information at the federal level. States may have a different approach.
Are you or the patient who is receiving the vaccine of 3 years of age and older? (If less than 18 years of age, parent/guardian must be present) *
*
Yes
No
Vaccine Recipient Name
*
First Name
Middle Name
Last Name
Vaccine Recipient Physical Address
*
Street Address
Apt #
City
State Initials
Zip Code
Date of Birth
*
/
Month
/
Day
Year
Gender at birth
*
Please Select
Male
Female
Race
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Ethnicity
*
Please Select
Hispanic or Latino
Not Hispanic or Latino
Unknown
Vaccine Recipient Phone Number
*
Format: (000) 000-0000.
Mother's Maiden Name
Required for proper vaccine documentation
Emergency Contact Name
Relationship to Emergency Contact
Please Select
Brother
Sister
Sibling
Mother
Parent
Father
Guardian
Spouse
Grandparent
Child
Foster child
Stepchild
Care Giver
Other
Phone Number of Emergency Contact
Format: (000) 000-0000.
Email
*
example@example.com
COVID-19 Vaccine Screen Questions
*
Rows
Yes
No
1. Are you feeling sick today?
2. In the last 10 days, have you had a COVID-19 Test because you had symptoms and are still awaiting your test results or been told by a healthcare provider or health department to isolate or quarantine at home due to COVID-19 infection, exposure, or travel?
3. Have you been treated with antibody therapy or convalescent plasma for COVID-19 in the past 90 days (3 months)?
4. 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
5.
Have you received any vaccine in the last 14 days
?
6. Are you pregnant or considering becoming pregnant or breastfeeding?
7. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
8. Do you take any medications that affect your immune system, such as cortisone, prednisone, or other steroids, anticancer drugs, or have you had any radiation treatments?
9. Do you have a bleeding disorder or are you taking a blood thinner?
10. Have you had a previous dose of the COVID-19 Vaccine?
Which arm would you like to get the injection on
*
Left Arm
Right Arm
Consent (check each box below after reading and prior to signing the form)
*
Rows
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 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 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.
Emergency Use Authorization
I understand
the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet, a copy of which I was provided. Emergency Use Authorization. The FDA has made the COVID-19 vaccine available under an emergency use authorization (EUA). The EUA is used when circumstances exist to justify the emergency use of drugs and biological products during an emergency, such as the COVID-19 pandemic. This vaccine has not undergone the same type of review as an FDA-approved or cleared product. However, the FDA’s decision to make the vaccine available is based on the totality of scientific evidence available, showing that known and potential benefits of the vaccine outweigh the known and potential risks. Please note: FDA approved the Pfizer-BioNTech COVID-19 vaccine as a two-dose series in individuals 16 years of age and older. The vaccine continues to be available under an EUA for certain populations, including for those individuals 5 through 15 years of age and for the administration of a third dose in the populations set forth in the consent section below.
Consent
I have read,
or had explained to me, the information sheet about the COVID-19 vaccination. I understand that if my vaccine requires two doses, I
will need to be administered (given) two doses to be considered fully vaccinated. Further, I understand that a booster dose of COVID-19 vaccine
may be recommended at least 2 months following the first dose of Janssen vaccine or at least 5 months following the second dose of PfizerBioNTech or Moderna COVID-19 vaccine if I am a member of a certain population (e.g., 65 years or older, 5 years old or older or a resident of a long term care facility, 50-64 years with an underlying medical condition, 18-49 years old with an underlying medical condition based on individual benefits and risks, 18-64 years old and at an increased risk for COVID-19 exposure and transmission because of working or living in a high-risk setting and based on individual benefits and risks) to increase my protection. I have had a chance to ask questions which were answered to my satisfaction (and ensured the person named above for whom I am authorized to provide surrogate consent was also given a chance to ask questions). I understand the benefits and risks of the vaccination as described.
I request
that the COVID-19 vaccination be given to me (or the person named above for whom I am authorized to make this request and provide
surrogate consent). I authorize release of all information needed (including but not limited to medical records, copies of claims and itemized bills) to verify payment and as needed for other public health purposes, including reporting to applicable vaccine registries.
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.
The vaccine is available to anyone no matter if insured or uninsured. Please check only one of the following.
*
If INSURED, check this box attesting to bringing in your prescription and medical insurance cards for your vaccine appointment. By selecting this, you are also authorizing the pharmacy to bill your insurance on your behalf for the immunization – understanding you will not incur any costs.
If UNINSURED, you must check this box to attest that the 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 benefit plan.
Please Upload Insurance Card
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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
Please Upload Supporting State ID/Passport/Social Security Card and/or Uninsured Document (must have valid ID for vaccination)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):
*
Date Signed
*
/
Month
/
Day
Year
Date
Pharmacist Name
First and Last Name
Pharmacist Signature
Immunizer Name
First and Last Name
Immunizer Signature
Lot Number
Expiration Date:
Vaccine Manufacturer
*
Moderna First Dose
Moderna Second Dose
Moderna Bivalent Booster Dose
Pfizer First Dose
Pfizer Second Dose
Pfizer Bivalent Booster Dose
Pediatric Pfizer Dose (Ages 5-11)
J&J 1st Dose
J&J Booster Dose
Pfizer (Ages: 6 months to 4 years old)
Moderna (Ages: 6 months to 5 years old)
Pharmacy Name
Submit
Pharmacy NPI
*
Should be Empty: