COVID-19 Vaccine Registration and Consent Form -QuickMDcare

Use this form in order to register and receive the Pfizer or Moderna vaccine. Visit this link (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations.html) for more information at the federal level. Visit this link (https://www.dshs.state.tx.us/coronavisus/immunize/vaccine.aspx) for more information at the state of Texas level. Visit this link for Pfizer emergency use authorization fact sheet (https://www.fda.gov/media/144414/download). Visit this link for Moderna emergency use authorization fact sheet (https://www.modernatx.com/covid19vaccine-eua/eua-fact-sheet-recipients.pdf).

Vaccine Recipient Name*

First NameMiddle NameLast Name

Date of Birth*

Gender*

Race:*

Vaccine Recipient Home Address*

Street Address

Street Address Line 2

CityState

Postal / Zip Code

Vaccine Recipient Phone Number*

Please enter a valid phone number.

Email

Mother's Maiden Last Name:*

Primary Care Provider Name:

Emergency Contact Name*

Relationship to Emergency Contact:*

Phone Number of Emergency Contact *

Please enter a valid phone number.

Do you have any chronic health condition?

Please indicate all health issues that are considered within the risk group

COVID-19 Vaccine Screen Questions*

	Yes	No
1. Have you been feeling sick in the last 5 days?
2. Have you ever received a dose of COVID-19 Vaccine?
3a. Have you ever had an allergic reaction to a component of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures?
3b. Have you ever had an allergic reaction to Polysorbate?
3c. Have you ever had an allergic reaction to a previous dose of COVID-19?
4. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?
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? This would include food, pet, environmental, or oral medication allergies.
6. Have you received any vaccine in the last 14 days?
7. Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19?
8. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? [note: monoclonal antibodies does not include antibiotics that you would be prescribed and filled at a pharmacy]
9. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immuno suppressive drugs or therapies?
10. Do you have a bleeding disorder or are you taking a blood thinner?
11. Are you pregnant or breastfeeding?

COVID-19 Vaccine Manufacturer that was used when you received your first dose previously (do not complete if you selected "no" to #2 above option.)

Required if you selected "Yes" to #2 above option

Date of first dose (do not complete if you selected "no" to #2 above option.)

Required if you selected "Yes" to #2 above option

COVID-19 Vaccine Manufacturer requested for first dose (for those who have not received COVID-19 vaccine previously):

Consent (check each box below after reading and prior to signing the form)*

	Yes	No
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet, of which I was provided with this Consent Form via a link. 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 21-28 days apart depending on the manufacturer. 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.

The vaccine is available to anyone no matter if insured or uninsured. Please check only one of the following:

I have health Insurance.I do not have health Insurance.

If you have insurance (Required if the patient has insurance. Information found on your card):

Insurance Name:   eg: Blue Cross Blue Shield

Primary Insured Member Name:   First Name Last Name

Vaccine recipient relation to Primary Insured Member:   e.g. spouse, child, self etc

Primary Insured Date of Birth:   MM-DD-YYYY

Insurance Member ID:

Skip to the next question if you do NOT have insurance.

Please provide a picture of the FRONT of your insurance card:

Please provide a picture of the BACK of your insurance card:

For uninsured patients, please select at least one of the following that you will bring with you to your appointment.

Social Security NumberState Identification Number (ID) and the State of Issuance or Passport NumberDriver's License (DL) Number and State of Issuance

Please enter the last 4 digits of your social security number:

Please enter your state ID or Driver's License number or Passport Number:

Please enter the State of issuance of your ID or Driver's License:

Please provide a picture of the front of your state issued ID or Driver's License or Passport.

Signature of Person to receive vaccine & EUA/VIS (or signature of Parent/Guardian). I understand the risks and benefits and consent to receiving the Pfizer COVID-19 Vaccine.*

Date Signed

Please select the dose of the vaccine you are scheduling.

Appointment Date

I hereby declare that all provided information is accurate.

Yes

Please verify that you are human*