COVID-19 Vaccine Screening Form

COVID-19 Vaccine Consent Form

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.
Select an appointment time*
Do you qualify to receive the COVID-19 Vaccine as per NY State Mandate and Guidance for vaccination?*

YesNo (Fill out the form and join our waitlist/standby) We will call contact you if available.
Which Vaccine Dose are you receiving?*

1st Dose2nd DoseAdditional DoseBooster Dose
Vaccine Manufacturer*

Moderna VaccinePfizer VaccineJanssen Vaccine
Vaccine Recipient Name*

First NameMiddle NameLast Name
Vaccine Recipient Physical Address*

Street Address

Apt #

CityState Initials

Zip Code
Vaccine Recipient Phone Number*
Date of Birth*

MonthDayYear
Gender at birth*
Race*
Ethnicity*
Mother's Maiden Name*
Required for proper vaccine documentation
Primary Care Provider Name
Emergency Contact Name*
Relationship to Emergency Contact*
Phone Number of Emergency Contact*
Email
example@example.com

COVID-19 Vaccine Screen Questions*

	Yes	No
1. Are you feeling sick today?
2. Have you ever received a dose of COVID-19 Vaccine?
3a. Have you ever had an allergic reaction to acomponent 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 Vaccine?
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 immunosuppressive drugs or therapies?
10. Do you have a bleeding disorder or are you taking a blood thinner?
11. Are you pregnant or breastfeeding?
12. Do you have dermal fillers?
13. Do you have a history of myocarditis or pericarditis?
14. Do you have a history of Guillain-Barre Syndrome (GBS)?
15. Have you been diagnosed with Multisystem Inflammatory Syndrome after a COVID19 infection?

Which arm would you like to get the injection on*

Left ArmRight Arm

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

	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 Janssen 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 understand that at this time, the Janssen COVID-19 vaccine requires 1 dose and Moderna/Pfizer requires two doses.
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.

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

Cancelof
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 and state of issuanceDriver's license number and state of issuance
Please Upload Supporting Uninsured Document

Cancelof
COVID-19 Booster Dose Self-Attestation Form

The CDC has approved a booster dose for all three COVID-19 Vaccine Products.

Pfizer-BioNTech or Moderna

For individuals who received a Pfizer-BioNTech or Moderna COVID-19 vaccine, the following groups are eligible for a booster shot at 6 months or more after their initial series is complete:

· 65 years and older

· Age 18+ who live in long-term care settings

· Age 18+ who have underlying medical conditions

· Age 18+ who work or live in high-risk settings

Janssen / Johnson & Johnson

People aged ≥18 years who received a single dose Janssen primary series (1 dose) should receive a COVID-19 booster dose at least 2 months after completing the primary series.
Date of First Dose

MonthDayYear
Date
By signing this form, I attest that all information I have provided on this form is true and accurate, thereby qualifying me to receive a COVID-19 vaccine booster dose

Clear
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):

Clear
Date Signed

MonthDayYear
Date
Pharmacist Name
First and Last Name
Pharmacist Signature

Clear
Immunizer Name
First and Last Name
Immunizer Signature

Clear
Lot Number
Expiration Date:
Pharmacy Name
Pharmacy NPI*
Should be Empty:

COVID-19 Vaccine Consent Form