COVID Form

2026-2027 COVID-19 Vaccine Consent Form
Name

First NameLast Name
Are you a resident of a Long Term Care facility or an employee/staff member ?
Facility Name
Gender
Date of Birth

MonthDayYear
Date
Any known Allergies?
Allergies:
List known allergies
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Pharmacy Insurance Card Name
We reserve the right to reject your vaccine if this section is filled out incompletely.
Pharmacy Insurance ID#
We reserve the right to reject your vaccine if this section is filled out incompletely.
Insurance Bin #
We reserve the right to reject your vaccine if this section is filled out incompletely.
Insurance PCN #
We reserve the right to reject your vaccine if this section is filled out incompletely.
Insurance Group #
We reserve the right to reject your vaccine if this section is filled out incompletely.
Upload a photo of Pharmacy Insurance Card

Cancelof
Social Security Number
This helps us obtain your correct insurance information if you provide us with the wrong card.
Any allergies or known contraindications?
YES,I would like to receive the selected 2026–2027 seasonal COVID-19 vaccine. My preferred vaccine is:
NO, I decline the COVID-19 vaccine.
Have you ever had an immediate allergic reaction (e.g., hives, facial swelling, difficulty breathing, anaphylaxis) to any vaccine, injection, or shot or to any component of the COVID-19 vaccine, or a severe allergic reaction(anaphylaxis) to anything?
Do you have a history of myocarditis (inflammation of the heart muscle) or pericarditis (inflammation of the liningaround the heart)?
Do you have a bleeding disorder, a history of blood clots or are you taking a blood thinner?
Do you have a history of MIS-C or MIS-A (multisystem inflammatory syndrome in children or multisystem inflammatory syndrome in adults)?
CONSENT OR DECLINATION AFFIRMATION: I have been offered the 2026–2027 seasonal COVID-19 vaccine. I have read or had explained to me the applicable Vaccine Information Statement(s), had the opportunity to ask questions, understand the benefits and risks, and consent to the vaccine(s) selected. If I decline vaccination and a suspected or confirmed outbreak occurs within the facility, I understand I may be required to follow the facility's infection prevention and isolation procedures.
Print Name
Should be Empty: