COVID-19 Vaccine Consent Form
Vaccine Recipient Name if patient is a child, please enter the Child's Name)
*
First Name
Middle Name
Last Name
Vaccine Recipient Physical Address
*
Street Address
Apt #
City
State Initials
Zip Code
Date of Birth
*
/
Month
/
Day
Year
Gender at birth
*
Please Select
Male
Female
Race
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Ethnicity
*
Please Select
Hispanic or Latino
Not Hispanic or Latino
Unknown
Patient's Age
Vaccine Recipient Phone Number
*
Format: (000) 000-0000.
Primary Care Provider Name
Emergency Contact Name
*
Relationship to Emergency Contact
*
Please Select
Brother
Sister
Sibling
Mother
Parent
Father
Guardian
Spouse
Grandparent
Child
Foster child
Stepchild
Care Giver
Other
Phone Number of Emergency Contact
*
Format: (000) 000-0000.
Email
example@example.com
Social Security Number or Medicare Number (if available)
Is the person to be vaccinated sick today?
Yes
No
Does the person to be vaccinated have an allergy to eggs or to a component of the vaccine?
Yes
No
Has the person to be vaccinated ever had Guillian-Barre syndrome?
Yes
No
Which arm would you like to get the injection on
*
Left Arm
Right Arm
Please upload a picture of your prescription insurance card if available. (By uploading your insurance card now will also reduce your wait time in the pharmacy) Please also bring in original at time of vaccination.
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Patient signature (Parent or guardian, if minor):
Date Signed
/
Month
/
Day
Year
Date
Pharmacist Name
First and Last Name
Pharmacist Signature
Immunizer Name
First and Last Name
Immunizer Signature
Lot Number
Expiration Date:
Pharmacy Name
Pharmacy NPI
*
PLEASE BRING YOUR INSURANCE CARD WITH YOU INTO THE PHARMACY.
Submit Consent Form (required)
Should be Empty: