COVID19 Vaccine Consent Form
Patient Information
Name
*
First Name
Last Name
Date of Birth
*
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Day
Year
Date
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Gender
*
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*
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Race
*
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Ethnicity
*
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Primary Care Provider Name
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Last Name
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Relationship
*
Emergency Contact Phone Number
*
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Screening Questions
1. Are you feeling sick today?
Yes
No
Don't Know
2. Have you ever received a dose of COVID-19 Vaccine?
*
Yes
No
Don't Know
2A. If you have received a dose of COVID-19 Vaccine before, what was the vaccine manufacturer (example: Pfizer, Moderna)?
2B. If you have received a dose of COVID-19 Vaccine before, what was the date of First dose?
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Month
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Day
Year
Date
2C. If you have received a second dose of COVID-19 Vaccine before, what was the date of the second dose?
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Month
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Day
Year
Date
2D. If you have received your first booster dose of COVID-19 Vaccine before, what was the date of your first booster dose?
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Month
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Day
Year
Date
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?
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Yes
No
Don't Know
3B. Have you ever had an allergic reaction to Polysorbate?
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Yes
No
Don't Know
3C. Have you ever had an allergic reaction to a previous dose of COVID-19 Vaccine?
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Yes
No
Don't Know
4. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?
*
Yes
No
Don't Know
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.
*
Yes
No
Don't Know
6. Have you received any vaccine in the last 14 days?
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Yes
No
Don't Know
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?
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Yes
No
Don't Know
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 would be prescribed to you and filled at a pharmacy]
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Yes
No
Don't Know
8B. If you have received passive antibody therapy treatment for COVID-19, please indicate when:
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?
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Yes
No
Don't Know
10. Do you have a bleeding disorder or are you taking a blood thinner?
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Yes
No
Don't Know
11. Are you pregnant or breastfeeding?
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Yes
No
Don't Know
12. Do you have dermal fillers?
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Yes
No
Don't Know
13. Do you have a history of myocarditis or pericarditis?
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Yes
No
Don't Know
14. Do you have a history of Guillan-Barre Syndrome (GBS)?
*
Yes
No
Don't Know
15. Have you been diagnosed with Multisystem Inflammatory Syndrome after a COVID19 infection?
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Yes
No
Don't Know
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Consent (check each box below after reading and signing):
*
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet (www.betterhealthfw.com/forms), 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 COVID-19 vaccine requires 2 doses given 21-28 days apart depending on the manufacturer. If this is my first dose of the COVID-19 vaccine, I intend to receive a second dose of the same vaccine in accordance with the timeframe specified in the Fact Sheet to complete the vaccination series.
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.
View Emergency Use Authorization (EUA) Fact Sheet
Select One of the Following:
If insured, please bring in your prescription and medical insurance cards for your vaccine appointment. I authorize the pharmacy to bill my insurance on my behalf for the immunization – understanding I will not incur any costs.
I do not have any insurance, including but not limited to, Medicare, Medicaid, or any other private or government-funded benefit plan.
For uninsured patients, please select at least one of the following that you will bring with you to your appointment. This is needed in order to have your vaccine administration fee paid for by the United States Health Resources & Services Administration's COVID-19 Program.
Social Security Number
State identification number and state of issuance
Driver's license number and state of issuance
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old)
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Clear
Date
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Month
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Day
Year
Date
Pharmacist Name
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