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. https://labeling.pfizer.com/ShowLabeling.aspx?id=16073&format=pdf
Vaccine Recipient Name *

First Name Middle Name Last Name
Vaccine Recipient Physical Address *

Street Address

Apt #

City State Initials

Zip Code
Date of Birth *

Month Day Year
Gender at birth *
Race *
Ethnicity *
Vaccine Recipient Phone Number *
Mother's Maiden Name *
Required for proper vaccine documentation
Primary Care Provider Name
Email *
example@example.com
Your choice of Covid-19 vaccine *
Vaccine dose number you are making the appointment for *

1st dose 2nd dose Booster dose under current eligibility criteria

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 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 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?

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 Moderna 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 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.

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

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

Social Security Number State identification number and state of issuance Driver's license number and state of issuance
Please Upload Supporting Uninsured Document

Cancel of
Moderna / Pfizer 3rd dose Eligibility (28 days after 2nd dose):

For Moderna 18 years of age or older and have a condition or are taking medications or treatments that moderately or severely weakens their immune system, and received either the Pfizer or Moderna vaccine are eligible for a third dose. Conditions and treatments may include:

• Active treatment for cancer

• Received an organ transplant and are taking immunosuppressive therapy

• Received a stem cell transplant within the past two years

• Moderate or severe primary immunodeficiency • Advanced or untreated HIV

• Active treatment with a high dose of corticosteroids or other drugs that moderately or severely weaken your immune system This is not a complete list.

The recommendation for a third dose is for people who have conditions like those listed above and not for most people with other medical conditions such as diabetes or heart or lung disease. If you have an immunocompromising condition or are taking drugs that weaken your immune system, discuss with your doctor whether you should get a third dose.

US CDC says that the third dose should be given at least four weeks after the second dose of the Pfizer (for above listed conditions) or Moderna vaccines
Moderna / Pfizer Booster Dose Eligibility:

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 2nd dose
Please check all that apply to you

Adults 65 years of age or older Adults 18-64 years old with underlying medical conditions that put them at high risk for severe COVID-19illness such as cancer, heart disease, diabetes, COPD, asthma Adults18 years and older who live in institutional settings Frontline workers 18 years and older whose occupation increases their exposure to the COVID-19 virus, such as healthcare workers, teachers/school staff members, grocery store/food processing workers
Moderna / Pfizer 1st dose date

Month Day Year
Date
Moderna / Pfizer 2nd dose date

Month Day Year
Date
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old): *

Clear
Date Signed *

Month Day Year
Date
Please download and read these documents before vaccination

For Moderna Vaccine Fact Sheet: English, Spanish

For Pfizer Vaccine Fact Sheet: English, Spanish

V-safe: English, Spanish
I hereby confirm that I have downloaded and read the fact sheet and V-Safe documents listed above. *

Yes
Signature *

Clear
Date Signed *

Month Day Year
Date
Pharmacy Name
Pharmacy NPI *
Should be Empty:

COVID-19 Vaccine Consent Form