COVID-19 Booster Shot Consent Form

COVID-19 Booster Shot Consent Form

(updated 9/8/2022) Bi-valent vaccine
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Facility Name or Home Address*
Insurance information, please fill if available
Eligibility
CDC recommends at least 2 months after 2nd dose or last booster, and can be Pfizer-BioNTech or Moderna. Has it been 2 months since the last dose as described?

YesNo
To find out more information about eligibility, please find the full article from CDC here.
Has primary series (Dose 1 and Dose 2, Pfizer & Moderna, Dose 1 for Janssen) been received?

YesNo
Eligible individuals may choose which vaccine they receive as a booster dose (Bivalent Pfizer or Bivalent Moderna). Some people may have a preference for the vaccine type that they originally received, and others may prefer to get a different booster. CDC’s recommendations now allow for this type of mix and match dosing for booster shots.

Botika LTC may not have all three COVID-19 vaccines at the time of clinic. Please check with the pharmacy prior to appointment or visit.
Pre-screening Checklist
Are you feeling sick today?

YesNo
Have you ever had an allergic reaction to a component of a COVID-19 vaccine, Polyethylene glycol (PEG), polysorbate, which is found in some vaccines, film coated tablets, and intravenous steroids or a previous dose of COVID-19 vaccine?

YesNo
Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?

YesNo
Check all that apply to you;

Am a male between ages 12 and 29 years oldHave a history of myocarditis or pericarditisHad a severe allergic reaction to something other than a vaccine or injectable therapy such as food, pet, venom, environmental or oral medication allergiesHad COVID-19 and was treated with monoclonal antibodies or convalescent serumDiagnosed with Multisystem Inflammatory Syndrome (MIS-C or MIS-A) after a COVID-19 infectionHave a bleeding disorderTake a blood thinnerHave a weakened immune system (i.e., HIV infection, cancer) or take immunosuppressive drugs or therapiesHave a history of heparin-induced thrombocytopenia (HIT)Am currently pregnant or breastfeedingHave received dermal fillersHistory of Guillain-Barré Syndrome (GBS)
Consent
I understand that:
- This vaccine is authorized for use under Emergency Use Authorization (EUA) issued by the U.S. Food and Drug Administration (FDA). Under an EUA, the FDA may allow the use of unapproved medical products, or unapproved uses of approved medical products, in an emergency to diagnose, treat, or prevent serious or life-threatening diseases or conditions when certain statutory criteria have been met, including that there are no adequate, approved, and available alternatives.
- Receiving this vaccine does not eliminate the need for masking, social distancing, and hand hygiene.
- I may still become ill with COVID-19 and may be able to transmit the virus to other individuals.
- This vaccine has not been studied on individuals who are pregnant or breastfeeding and it is recommended that I discuss vaccination with my provider prior to receiving vaccine.
- I agree to remain at the vaccination location for at least 15 minutes after vaccine is administered in the event of adverse reaction.
- I agree that I have read the Emergency Use Authorization (EUA), and I have had the opportunity to ask questions and I have received satisfactory answers.
I understand and acknowledge record of this vaccine administration to me will be reported to the state and/or federal regulatory bodies in compliance with reporting for inventory management. I agree and authorize my COVID-19 vaccine record to be shared with my primary care physician and included in my health record(s) for continuity of care of care purposes.
Signature*

Clear
Name of Signatory*

PrefixFirst NameLast Name
Email
A copy will be sent to you.
This form asks for private health information. An email will be sent to you after submitting this form however sensitive information will be hidden. Although information was provided by you, you will not be able to see most entries on the confirmation email. This is to protect your information in case the email address provided was incorrect or email was forwarded to an unintended recipient.

You are welcome to call the pharmacy to verify the information you have sent.
Should be Empty:

COVID-19 Booster Shot Consent Form

Eligibility

Pre-screening Checklist

Consent