Vaccine Consent Form
Bring any form of ID and insurance card to your appointment
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Male
Female
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of your Doctor
First Name
Last Name
Doctors Phone Number
Please enter a valid phone number.
Is this for an upcoming clinic (school, facility, etc) or a regular pharmacy appointment?
*
Clinic
Pharmacy
Type of Vaccine
*
Pfizer - COMIRNATY VACCINE (12 years & over)
Moderna - SPIKEVAX (12 years & over)
Which arm would you like to receive your vaccine in today?
*
Left Arm
Right Arm
Appointment
*
Are you feeling sick today?
*
Yes
No
Have you ever received a dose of COVID-19 Vaccine?
*
Yes
No
Have you ever had an allergic reaction to a component of the COVID-19 vaccine, including PEG(polyethylene glycol), which is found in some medications, such as laxative, and preparation for colonoscopy procedures?
*
Yes
No
Have you ever had a serious reaction to a previous dose of COVID-19 vaccine?
*
Yes
No
Please indicate below
Do you have any health conditions, such as heart disease, diabetes or asthma?
*
Yes
No
Please indicate your health conditions below
Have you received any vaccine in the last 14 days?
*
Yes
No
Please list below
Have you ever had a posivite COVID-19 or has a health care provider ever told you that you had COVID-19?
*
Yes
No
Do you have a bleeding disorder or are you taking a blood thinner?
*
Yes
No
Have you received passive antibody therapy(monoclonal antibodies) as treated for COVID-19
*
Yes
No
Don't know
Have you taken antibiotics in the last 14 days or antimalarials in the last 10 days?
*
Yes
No
Are you pregnant or planning to be pregnant in the next 30 days
*
Yes
No
Do you have a history of myocarditis or pericarditis?
*
Yes
No
Do you have a history of Guillain-Barre Syndrome (GBS)?
*
Yes
No
Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
Yes
No
Insurance Information
*
I have medicare
Commercial insurance
I do not have insurance
Please upload a picture of the front of your Prescription Insurance card here:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please upload a picture of the front of your Medical Insurance card here:
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Drag and drop files here
Choose a file
Cancel
of
(If applicable) Please upload a picture of the front of your Medicare/Aetna Medicare/Part B insurance card here:
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Choose a file
Cancel
of
Medicare Number (red, white, and blue card)
I hereby give my consent to the administering of the flu vaccine as specified to the choice above. I acknowledge the risks and benefits in administering of the vaccine. I likewise understand that such risks of having side effects or complications associated with the receiving of the vaccine cannot be predicted. I have been advised to stay in the facility for at least 15 minutes after the vaccine has been given to me for observation. I hereby release and hold harmless the facility, its staff, agents, employees, successors, affiliates, subsidiaries, directors, and officers from any and all liabilities or claims whether known or unknown arising from, or in connection with the administration of the vaccine listed above. I authorize the disclosure of my information for the purpose of necessary processing, recording of my information relevant to the administering of the vaccine including claims for costs and fees. I agree to be responsible for any financial cost-sharing amounts, including copays, coinsurance, and other deductibles including those which are not covered by my insurance benefits.
Age of Consent
I hereby declare that I am of legal age and I give my consent with full knowledge and responsibility to the risks and benefits of the vaccine. I have had the opportunity to ask questions and which answers were given to me to my satisfaction.
I am the legal representative of the above-named patient. The patient is of legal age and I am executing this document on his/her behalf. He/she have had the opportunity to ask questions and which the answers were provided to him/her to his/her satisfaction.
I am the legal guardian of the above-named patient. I am executing this document on his/her behalf with my full consent and authority. I have had the opportunity to ask questions and by which answers were given to me to my satsifaction.
Name
*
First Name
Last Name
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: