Covid Vaccine Consent Form

Covid-19 Vaccination Consent Form

For Tanque Verde Pediatrics Patients/Parents, aged 12 and up. Please call the office at 520-722-2585 to schedule the actual appointment time and date.
Parent or Child to be Vaccinated: Full Name *

First Name Last Name
Person to be vaccinated: DOB and Age *

DOB Age on 5/22/2021
Best number to contact parent/guardian: *

Area Code Phone Number
Parent/Person to be vaccinated E-mail *
Patient Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Insurance Information

Insurance Company Name

Name of primarily insured parent/guardian

Group Number Member ID

DOB of primarily insured
Has the person being vaccinated ever received a dose of Covid-19 vaccine? *

Yes No
If yes, which vaccine did he/she/they receive?

Pfizer Moderna Janssen (JnJ) NA
Is this a first vaccine, a second vaccine or a booster?

First dose Second dose Booster
If this is your or your child's second shot or booster, what was the date of their first (and or second)(please note that there must be TWENTY ONE DAYS between dose one and two)?
Dates of 1st or 2nd shots
Has the person being vaccinated ever had an allergic reaction to A COMPONENT OF A COVID-19 VACCINE INCLUDING ANY OF THE FOLLOWING: POLYETHYLENE GLYCOL (PEG), which is found in some laxatives and preparations for colonoscopy procedures, POLYSORBATE, which is found in some vaccines, film coated tablets and IV steroids, A PREVIOUS DOSE OF COVID-19 VACCINE, or A VACCINE OR INJECTABLE THERAPY THAT CONTAINS MULTIPLE COMPONENTS, ONE OF WHICH IS A COVID-19 VACCINE COMPONENT, BUT IT IS NOT KNOWN WHICH COMPONENT ELICITED THE IMMEDIATE REACTION? *

Yes No Don't Know
Has the person being vaccinated ever had a severe allergic reaction (anaphylaxis) to something other than a component of COVID-19 vaccine, or any vaccine or injectiable medication? This would include food, pet, venom, environmental, or oral medication allergies. *

Yes No Don't Know
Has the person being vaccinated received any vaccine in the last 14 days? *

Yes No Don't Know
Has the person being vaccinated ever had a positive test for COVID-19 or has a doctor told him/her/they that they had COVID-19? *

Yes No Don't Know
Has the person being vaccinated ever received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? *

Yes No Don't Know
Does the person being vaccinated have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies? *

Yes No Don't Know
Does the person being vaccinated have a bleeding disorder or are they taking a blood thinner? *

Yes No Don't Know
Is the person being vaccinated pregnant or breastfeeding? *

Yes No Don't Know
Does the person being vaccinated have dermal fillers? *

Yes No Don't Know
**Please note that a "yes" answer does not mean that you won't get vaccinated. It just means that further questions may need to be asked on the day of vaccination to ensure safety.

**If this is the second shot or booster, please bring his/her/their vaccination card to your appointment.

**Please arrive on time so we can keep the traffic flowing well. The shots will be given in the building, and the 15 minute wait time will take place in a private exam room (one family per room) to promote safety.
Signature *

I am the legal guardian of the person to be vaccinated and consent to administration of Pfizer COVID-19 vaccine. I have received the Pfizer EUA and have reviewed it. I know to come back to clinic for my child's second dose in 3 weeks. I also consent to the reporting of this vaccine to my state's immunization reporting system (ASIIS). Clear
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Covid-19 Vaccination Consent Form