COVID-19 VACCINE
Consent Form PFIZER-BIONTECH COVID-19 Vaccine
Name
First Name
Last Name
Social Security Number
Date of Birth
-
Month
-
Day
Year
Date
Gender
Female
Male
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
ID Number
Race
Please Select
American Indian or Alaska Native
Native Hawaiian or Other
Other Asian
Unknown
Asian
Pacific Islander
Other Non-White
White
Other
Pacific Islander
Primary Insurance
Carrier ID #
Group ID #
Insurance Company
Relationship
Date of Birth
-
Month
-
Day
Year
Date
Secondary Insurance Carrier ID#
Group #
Insurance Company
Insurance Company Phone Number
Please enter a valid phone number.
Insured's Name
Relationship
Insured's Date of Birth
-
Month
-
Day
Year
Date
Is this the patient's first or second dose of the COVID-19 vaccination?
Please Select
First Dose
Second Dose
Third Dose
Fourth Dose
Bivalent Dose
COVID-19 Screening Questions
Please check YES or NO for each question
Do you have today or have you had at any tijme in the last 10 days a fever, chills, cough, shortness of breath, difficulty breathing, fatigue muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea, vomiting, or diarrhea?
Yes
No
Have you tested positive for and/or been diagnosed with COVID-19 infection within the last 10 days?
Yes
No
Have you had a severe allergic reaction (e.g. influenza vaccine, etc)?
Yes
No
Have you had any COVID-19 Antibody therapy within the last 90 days (e.g. Regeneron, Bamlanivimbab, COVID Convalescent Plasma, etc.)?
Type option 1
Type option 2
Type option 3
Type option 4
Immunization Screening Guidance For COVID-19 Vaccine
Please check YES or NO for each question
Do you carry an Epi-pen for emergency treatment of anaphylaxis or have allergies or reactions to any medications, foods, vaccines or latex?
Yes
No
For women, are you pregnant or is there a chance you could becojme pregnant?
Yes
No
For women, are you currently breastfeeding?
Yes
No
Are you immunocompromised or on medication that affects your immune system?
Yes
No
Pfizer-Biontech COVID-19 Vaccine effective date: 1/04/2021
Please check YES or NO for each question
Do you have a bleeding disorder or are you on a blood thinner/blood-thinning medication?
Yes
No
Have you received a previous dose of any COVID-19 vaccine? If yes, which manufacturer's vaccine did you receive?
Yes
No
If yes, which manufacturer's vaccine did you receive?
Consent
I certify that I am: (a) the patient and at least 18 years of age; (b) the parent or legal guardian of the patient and confirm that the patient is at least 16 years of age; or (c) authorized to consent for vaccination for the patient named above. Further, I hereby give my consent to the Florida Department of Health (DOH) or its agents to administer the COVID-19 vaccine.I understand that this product has not been approved or licensed by FDA, but has been authorized for emergency use by FDA, under an EUA to prevent Coronavirus Disease 2019 (COVID-19) for use in individuals 16 years of age and older, and the emergency use of this product is only Page 1 of 2 Pfizer-BioNTech COVID-19 Vaccine Effective Date: 1/04/2021 authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of the medical product under Section 564(b)(1) of the FD&C Act unless the declaration is terminated or authorization revoked sooner.I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccine(s). I understand the risks and benefits associated with the above vaccine and have received, read and/or had explained to me the Emergency Use Authorization Fact Sheet on the COVID-19 vaccine I have elected to receive. I also acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction.I acknowledge that I have been advised to remain near the vaccination location for approximately 15 minutes after administration for observation. If I experience a severe reaction, I will call 9-1-1 or go to the nearest hospital.On behalf of myself, my heirs and personal representative, I hereby release and hold harmless the State of Florida, the Florida Department of Health (DOH), and their staff, agents successors, divisions, affiliates, subsidiaries, officers, directors, contractors and employees from any and all liabilities or claims whether known or unknown arising out of , in connection with, or in any way related to the administration of the vaccine listed above.I acknowledge that: (a) I understand the purposes/benefits of Florida SHOTS, Florida's immunization registry and (b) DOH will include my personal immunization information Florida SHOTS and my personal immunization information will be shared with the Centers for Disease Control (CDC) or other federal agencies.I further authorize DOH or its agents to submit a claim to my insurance provider or Medicare Part B without supplemental coverage payment for me for the above requested items and services. I assign and request payment of authorized benefits be made on my behalf to DOH or its agents with respect to the above requested items and services. I understand that any payment for which I am financially responsible is due at the time of service or if DOH invoices me after the time of service, upon receipt of such invoice.I acknowledge receipt of the Notice of Privacy Rights.
Signature
Print Name of Patient or Authorized Representative:
First Name
Last Name
Print Name of Representative and Relationship to Person Receiving Vaccine:
Submit
Should be Empty: