COVID-19 Vaccine Consent Form
Please read below carefully and ask for help if you need or call 727-842-3400
The COVID-19 vaccine will reduce the risk of being suffering from the new type of Coronavirus disease as known as COVID-19. Please be aware that the vaccine is not completely effective like all other medicines. It can take a few weeks for your body to build up protection from the vaccine. There is always a chance to get infected by Coronavirus even with the vaccine; however, the vaccine lessens the severity of any infection. Two doses will reduce the chance of being seriously ill and reduce the risk of death due to Coronavirus. You still need to follow the health instructions in your workplace and in public areas, such as wearing a mask and keeping the distance from others after you received the COVID-19 vaccine. The vaccine has some side effects as the other vaccines/medicines, but not everyone gets them. The most likely side effects that you may experience from the vaccine Fever Pain at the injection site Redness and hardness of the skin at the injection site Headache Muscle aches or pain Joint aches or pain Fatigue (tiredness) Nausea/vomiting Chills Underarm gland swelling on the side of study vaccination If you think you are experiencing any side effects, please remain calm and see your doctor immediately. If you are currently pregnant or planning to get pregnant or your partner is planning to get pregnant; please see your doctor before getting vaccinated.
Please Choose Manufacturer Desired
*
Jansen Covid-19 Vaccine (J&J)
Moderna Covid-19 Vaccine
Pfizer Covid-19 Vaccine
Dose Series
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Dose 1
Dose 2
Dose 3 (Booster)
Dose 4 (Booster)
Medical History
*
Yes
No
Don't know
Do you have allergies to latex, food, medications, or vaccine components? (such as eggs, thimerosal, gelatin, neomycin, phenol, or bovine protein)?
Did you ever experience any serious reaction after getting a vaccine?
In the past year, did you receive a transfusion of blood or blood products, or get injected immune (gamma) globulin or any antiviral drug?
Did you have any brain or other nervous system problems?
Have you get vaccinated in the last 4 weeks?
Are your pregnant or planning to get pregnant or your partner is planning to get pregnant?
Notes
Do you have any of the followings? (select all that apply)
Lung disease
Heart disease
Asthma
Kidney Disease
Diabetes
Anemia
Blood disorder
None
Do you have immunocompromised condition? (select all that apply)
Cancer
Leukemia
Lymphoma
HIV/AIDS
Transplant
Asplenia
CSF leak
Cochlear implant
None
Have you ever tested positive for COVID-19?
Yes
No
Test Date
-
Month
-
Day
Year
Date
In the last 14 days, have you contacted with a person who was confirmed to have COVID-19?
Yes
No
Not sure
In the last 14 days, have you travelled internationally?
Yes
No
Do you have any of the followings?
Cough
Cold
Fever
Shortness of breath
Sore throat
Loss of smell/taste
Abdominal pain/diarrhea
Abnormal bruising or bleeding/eye redness
Personal Information
Name
First Name
Last Name
Date of Birth
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance ID no. If Applicable
Insurance Group no. If Applicable
Insurance BIN no. If Applicable
Insurance PCN no. If Applicable
Emergency Contact Information
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Relation
By signing this form, I hereby accept that I have read and understood the acknowledgment letter provided above. I declare that the information I have provided above is correct. I am giving my full consent to get the COVID-19 vaccine of my own will.
Date
-
Month
-
Day
Year
Date
Signature
Submit
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