COVID-19 Vaccine Consent Form
COVID-19 vaccines are available for children ages 3 years and older. CDC recommends that people ages 5 years and older receive one updated (bivalent) booster if it has been at least 2 months since their last COVID-19 vaccine dose. Visit this link (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/booster-shot.html) for more information at the federal level.
Select an appointment time
Vaccine Recipient Name
Vaccine Recipient Physical Address
Street Address Line 2
Postal / Zip Code
Are you (the vaccine recipient) at least 3 years old?
Date of Birth
Gender at birth
American Indian or Alaska Native
Black or African American
Native Hawaiian or Other Pacific Islander
Hispanic or Latino
Not Hispanic or Latino
Vaccine Recipient Phone Number
Primary Care Provider Name
Emergency Contact Name
Phone Number of Emergency Contact
Relationship to Emergency Contact
Which Vaccine Would you like to receive
(12 years or older) Pfizer Bivalent (UPDATED!!) Booster
(3-5 years old) Moderna Pediatric 1st or 2nd dose
(3-5 years old) Moderna Pediatric BiValent (UPDATED!!) Booster
(6 years or older) Moderna 1st or 2nd dose
(6 years or older) Moderna BiValent (UPDATED!!) Booster
COVID-19 Vaccine Screen Questions
1. Are you feeling sick today?
2. In the last 10 days, have you had a COVID-19 test because you had symptoms and are still awaiting your test results or been told by a health care provider or health department to isolate or quarantine at home due to COVID-19 infection or exposure?
3a. Have you ever had an immediate allergic reaction to any 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?
4. Have you ever had an immediate severe allergic reaction (e.g., hives, facial swelling, difficulty breathing, anaphylaxis) to anything?
5. Have you been treated with antibody therapy or convalescent plasma for COVID-19 in the past 90 days (3 months)? If yes, when did you receive the last dose? Date: __________
6. Do you have cancer, leukemia, HIV/AIDS or any other condition that weakens the immune system?
7. Do you take any medications that affect your immune system, such as cortisone, prednisone or other steroids, anticancer drugs, or have you had any radiation treatments?
Do you have a bleeding disorder, a history of blood clots or are you taking a blood thinner?
9. Do you have a history of myocarditis (inflammation of the heart muscle) or pericarditis (inflammation of the lining around the heart)?
10. Have you had Guillain-Barre Syndrome after receipt of the Janssen vaccine?
11. Do you have a history of MIS-C or MIS-A (multisystem inflammatory syndrome in children or multisystem inflammatory syndrome in adults)?
12. (For Booster recipients only!) Are you 3 years old or older, and has
it been 2 months or longer since your last COVID-19 vaccine?
13. If you had a previous dose of Janssen (Johnson & Johnson), did you develop thrombosis with thrombocytopenia syndrome (TTS)?
14. (For women) Are you pregnant, considering becoming pregnant or breastfeeding?
Which arm would you like to get the injection on
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.
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 your Prescription insurance card
Consent (check each box below after reading and prior to signing the form)
Check each box
I have read, or had explained to me, the information sheet about the COVID-19 vaccination. I understand that if my vaccine requires two doses, I will need to be administered (given) two doses to be considered fully vaccinated. Further, I understand that a booster dose of COVID- 19 vaccine is recommended at least 2 months following the completion of a COVID-19 vaccine primary series or a monovalent booster dose to increase my protection.
I have had a chance to ask questions which were answered to my satisfaction (and ensured the person named above for whom I am authorized to provide surrogate consent was also given a chance to ask questions). I understand the benefits and
risks of the vaccination as described.
I request that the COVID-19 vaccination be given to me (or the person named above for whom I am authorized to make this request and provide surrogate consent). I understand there will be no cost to me for this vaccine. I understand that any monies or benefits for administering the vaccine will be assigned and transferred to the vaccinating provider, including benefits/monies from my health plan, Medicare or other third parties who are financially responsible for my medical care. I
authorize release of all information needed (including but not limited to medical records, copies of claims and itemized bills) to verify payment and as needed for other public health purposes, including reporting to applicable vaccine registries.
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):
Submit Consent Form (required)
Should be Empty: