Vaccine Consent Form (with COVID) - 2023

  • VACCINE INFORMED CONSENT FORM

  • PATIENT INFORMATION

  • Date of Birth*
     / /
  • Gender
  • Format: (000) 000-0000.
  • Are you Hispanic or Latino?*
  • Which vaccine(s) would you like to receive?

  • Please call the pharmacy for COVID-19 availabilty before heading out there.

    Phone # 713-783-5704

  • Have you had a vaccine for COVID-19 previously?*
  • Date of last dose*
     - -

  • SCREENING QUESTIONS

    Please select the correct option below.
  • Do you feel sick today?*
  • Have you had COVID-19 within the last three months?*
  • Have you received any immunizations in the past 4 weeks?*
  • Do you have an allergy to medications, foods or any vaccines?*
  • Have you ever had a serious reaction or fainted after receiving any vaccination?*
  • Do you carry an EpiPen?*
  • Have you been diagnosed with Multisystem Inflammatory Syndrome (MIS-C or MIS-A) after a COVID-19 infection?*
  • Have you had a new onset of fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, nausea, vomiting or diarrhea?*
  • In the past 3 months, have you taken medications that affect immune system such as prednisone, other steroids, or anticancer drugs, drugs for autoimmune disease (RA, Crohn’s, etc.) or had radiation?*
  • Do you have a bleeding disorder or take a blood thinner?*
  • Have you ever had a seizure disorder, brain disorder, or Guillain-Barre Syndrome?*
  • Do you have cancer, leukemia, HIV/AIDS, history of a transplant, or an autoimmune disorder?*
  • Do you have a history of myocarditis or pericarditis?*
  • Have you received hematopoietic cell transplant (HCT) or CAR-T-cell therapies since receiving COVID-19 vaccine?*
  • During the past year, have you received a transfusion of blood or blood products or been given a medicine called immune (gamma) globulin or an antiviral drug?*
  • Do you have a long-term health problem with heart, lung, kidney, diabetes, asthma, no spleen, cochlear implant, anemia or a blood/bleeding disorder?
  • FOR WOMEN: Are you pregnant or are you planning on becoming pregnant during the next month?*
  • FOR CHILDREN AGES 2-4: Has a healthcare provider told you that the child had wheezing or asthma in the past 12 months?*
  • FOR CHILDREN/TEENS: Has the child, sibling, or parent had a seizure; has the child had brain or other nervous system problems?*
  • FOR THOSE 50+: Have you had a shingles vaccination or been diagnosed with shingles in last 12 months?*
  • FOR THOSE 65+: Have you ever had a pneumococcal vaccination?*
  • Pick your appointment
  • INSURANCE INFORMATION*

  • Moderna COVID-19 12+ VIS  |  Moderna COVID-19

    Pfizer COVID-19 12+ VIS  |  Pfizer COVID-19

     

    Flu Injection VIS  |  Flu Mist VIS

     

    Pneumonia VIS  |  Shingles VIS  |  RSV VIS

     

    Other Vaccine Information Statements can be found by clicking here

  • ACKNOWLEDGEMENTS
  • Date
     / /

  • By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.

  • Should be Empty: