COVID-19 Consent Form

  • COVID-19 VACCINE CONSENT FORM

  • Format: (000) 000-0000.
  • Gender at birth*

  • Vaccination Status

  • Have you received a COVID-19 vaccine?*
  • If yes, which vaccine did you receive?*
  • If no, which vaccine would you prefer to receive?*
  • Date of birth*
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  • Date of birth*
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  • Which booster vaccine would you prefer to receive?*
  • Date of First Dose*
     / /
  • For Pfizer or Moderna recipients: which dose of COVID-19 vaccine will this be?*
  • Date of First Dose*
     / /
  • Date of Second Dose
     / /

  • COVID-19 VACCINATION ATTESTATION FOR ADDITIONAL DOSE

    This attestation form is used to verify your eligibility to receive an additional dose of COVID-19 vaccine and is currently only for those who received Pfizer or Moderna two-dose primary series.
  • Please mark any of the following conditions that you meet*

  • For moderately to severely immunocompromised a third dose is recommended at least 28 days after the date of the second dose. You will receive the vaccine from the same manufacturer as you received for your primary series.

  • Please mark any of the following conditions that you meet

  • For adults age 65 or older, those with underlying medical conditions, or those who work and/or live at an increased risk, a booster dose is recommended at least 6 months after the date of the second dose. You may choose which manufacturer’s vaccine you would like to receive for the booster dose.

  • Which booster vaccine would you prefer to receive?*
  • By signing below, I attest that I meet one or more of the criteria listed above.
  • Date*
     / /

  • Screening Questionnaire

  • Are you feeling sick today?*
  • Have you ever received a dose of COVID-19 vaccine?*
  • Have you ever had an allergic reaction to a component of a COVID-19 vaccine, including Polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures?**
  • Have you ever had an allergic reaction to a component of a COVID-19 vaccine, including Polysorbate, which is found in some vaccines, film coated tablets, and intravenous steroids?**
  • Have you ever had an allergic reaction to a previous dose of COVID-19 vaccine?*
  • Do you carry an EpiPen?*
  • Have you ever had an allergic reaction to another vaccine (other than COVID-19) or an injectable medication?**

  • *This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that caused hives, swelling, or respiratory distress, including wheezing.

  • Select all that apply*

  • Insurance Information

  • Please select one of the following*
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  • Policy Holder's Date of Birth*
     / /
  • To have your vaccine administration fee paid for by the United States Health Resources & Services administration's COVID-19 Program for uninsured patients, please provide one of the following:*
  • ACKNOWLEDGEMENTS

  • Pfizer Vaccine Information Sheet (VIS)

    Pharmacy Notice of Privacy Practices

  • Moderna Emergency Use Authorization (EUA)

    Pharmacy Notice of Privacy Practices

  • Janssen/Johnson and Johnson Emergency Use Authorization (EUA)

    Pharmacy Notice of Privacy Practices

  • Schedule Your Appointment*
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