COVID-19 VACCINE Consent Form

  • COVID-19 VACCINE

    Consent Form PFIZER-BIONTECH COVID-19 Vaccine
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  • Gender

  • Primary Insurance

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  • Format: (000) 000-0000.
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  • 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?
  • Have you tested positive for and/or been diagnosed with COVID-19 infection within the last 10 days?
  • Have you had a severe allergic reaction (e.g. influenza vaccine, etc)?
  • Have you had any COVID-19 Antibody therapy within the last 90 days (e.g. Regeneron, Bamlanivimbab, COVID Convalescent Plasma, etc.)?

  • 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?
  • For women, are you pregnant or is there a chance you could becojme pregnant?
  • For women, are you currently breastfeeding?
  • Are you immunocompromised or on medication that affects your immune system?

  • 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?
  • Have you received a previous dose of any COVID-19 vaccine? 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.
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