Covid-19 Booster Vaccine Consent Form

NAME (Last)

(First)

Date of Birth

Date

Age

EMAIL

example@example.com

Daytime Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Gender:

Emergency Contact Name:

Relation

Phone Number

Format: (000) 000-0000.

1.Are you feeling sick today?

2. Did you have a severe reaction to any COVID-19 vaccination received?

Pfizer 1st dose

Pfizer 2nd dose

Moderna 1st dose

Moderna 2nd dose

J&J dose

Other Name

1st dose

2nd dose

4. Has it been at least six months since your second COVID-19 vaccination? (Pfizer, Moderna, Other)

5. Has it been at least two months since your J&J COVID-19 vaccination?

I, the undersigned, wish to receive the Pfizer COVID 19 BOOSTER vaccine. I understand that the Covid19 booster shot eligibility is open to all adults 18 and older to allow for use of a single booster dose, to be administered at least six months (Pfizer and Moderna) and two months (J&J) after completion of the primary series. I hereby certify that the foregoing answers to the healthquestions are true and complete to the best of my knowledge. I understand that a “YES” response to any of the health questionsabove may require that a Fast Track Testing LLC provider talk with me prior to getting the Pfizer/Moderna COVID 19 BOOSTER vaccine at a Fast Track Testing LLC.understand the benefits and risks of the Pfizer COVID BOOSTER vaccine and had the chance to ask questions. I have been advised to remain on site for 15 minutes after receiving the vaccine.For any reaction to a previous COVID19 vaccination, I have been advised to stay for 30minutes.

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