Office Covid19 Vaccination Consent Form

COVID-19 Vaccination Program

Immunization Consent and Appointment System

COVID-19 Vaccine For Anyone 6 months and older

Please have your ID and health insurance information on hand (if applicable), you will be asked to provide this information during registration.

If you experience difficulties, please contact 915-533-3414 (Mon-Fri 8A-5P)

Stay Up to Date with COVID-19 Vaccines
Screening Questionnaire

The following questions will help us determine if there is any reason we should not give you a Influenza/COVID-19 vaccination.

COVID-19 Screening Questionnaire *

	Yes	No
Is the person to be vaccinated currently under quarantine or isolation orders for COVID-19?
Do you have any COVID-19 or influenza-like symptoms? (Fever, cough, loss of sense of smell or taste, breath, sore throat, runny nose or congestion, nausea or vomiting, diarrhea)
Has a physician or medical provider indicated that the person being vaccinated should NOT receive the COVID-19 vaccine?
Have you ever had a serious reaction to a vaccine or a severe allergic reaction that required going to ER?

Unfortunately, based on your responses, you are not eligible to continue with the online consent application for Influenza immunization. Please call 915-533-3414 or speak with your physician for additional guidance.

Do you have health insurance?*

Patient Registration
Who are you completing this form for? For children, a parent or guardian must complete this form. *
Will you be attending the clinic with your child or dependent?*

YesNo
Patient Name*

First NameMiddle NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Gender*
Phone Number*

Area CodePhone Number
Personal email address*

Confirmation Emailexample@example.com
Race*
Please describe your ethnicity*
Parent, Guardian, Or Individual of Record*

First NameMiddle NameLast Name
Texas Vaccines for Children(TVFC)Program Patient Eligibility*

Health Insurance Information

If you are insured, we ask for insurance information so Immunize El Paso can be reimbursed for the cost and administration of the vaccine through your insurance company. If your insurance is not listed below, we are unable to process claims through your insurance.
If insurance is HMO a doctor's pre-authotization number is needed.

Please stop by any clinic to do a physical registration.
Select Your Insurance:*
Patient Social Security Number*
Member ID Number*
Group Number*
To whom is this policy issued:*
Policy Holder Name*

First NameLast Name
Policy Holder SSN*
State/GVMT Issued ID*

Browse Files

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Photo of insurance card - FRONT*

Browse Files

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Photo of insurance card - BACK*

Browse Files

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COVID-19 Vaccine Notice for Uninsured Patients
If you do not have insurance, please be advised that there may be a cost associated with receiving the COVID-19 vaccine at this location. For those seeking free or reduced-cost vaccination resources, we recommend contacting Texas 2-1-1 or the City of El Paso Public Health Department at https://www.epcovidvaccine.com/. They can provide information on available resources and vaccination sites that may offer the vaccine at no cost.

Stay safe and thank you for doing your part to protect our community.

Vaccination Consent Form
Updated 2024-2025 COVID-19 Vaccine Recommendation

CDC recommends everyone ages 6 months and older receive an updated 2024-2025 COVID-19 vaccine to protect against the potentially serious outcomes of COVID-19 this fall and winter whether or not they have ever previously been vaccinated with a COVID-19 vaccine. Updated COVID-19 vaccines will be available from Moderna and Pfizer. This recommendation will take effect as soon as the new vaccines are available.

The virus that causes COVID-19, SARS-CoV-2, is always changing and protection from COVID-19 vaccines declines over time. Receiving an updated 2024-2025 COVID-19 vaccine can restore and enhance protection against the virus variants currently responsible for most infections and hospitalizations in the United States. COVID-19 vaccination also reduces the chance of suffering the effects of Long COVID, which can develop during or following acute infection and last for an extended duration.

Last season, people who received a 2023-2024 COVID-19 vaccine saw greater protection against illness and hospitalization than those who did not receive a 2023-2024 vaccine. To date, hundreds of millions of people have safely received a COVID-19 vaccine under the most intense vaccine safety monitoring in United States history.

COVID-19 Vaccine Consent

I have received, read, and understand the COVID-19 Vaccine Information provided by ProAction, Inc. I hereby authorize ProAction, Inc. and the practitioners employed by or contracted with ProAction, Inc. (each, a “Provider”) to administer the Vaccine I have requested above as a two-dose regimen series administered in accordance with manufacturer and CDC recommendations (the “Services”). The scope of this consent includes discussion about the vaccine(s) and its administration between ProAction, Inc., and other health care professionals for purposes of care and treatment. I understand that I may withdraw this consent at any time by making a request in writing.

I acknowledge that I have been informed about, the following:

• The goal of the Services is to administer the Vaccine I requested.

• The Provider(s) will provide me with additional information about any risks associated with the Services, depending on my specific diagnoses and health status.

• Administering Vaccines is not an exact science, and there are no guarantees as to the results of the Services that may be provided to me.

• The nature and purpose of the Services, expected benefits, potential known and unknown complications, the likelihood of achieving goals, and relative risks that may arise from the Services, along with the relevant risks and consequences of no treatment.

I understand the benefits and risks of the Vaccine, and I expressly consent, request, and authorize the administration of the Vaccine. On behalf of myself, my heirs, and personal representatives, I hereby release and hold harmless Pro-Action, Inc, each Provider, and the applicable staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors, and employees from any and all liability or claims, whether known or unknown, arising out of, in connection with, or in any way related to the Services. I acknowledge that: (a) I understand the purposes/benefits of my state’s vaccination registration (“State Registry”) and my state’s health information exchange (“State HIE”); and (b) the Provider may disclose my vaccination information to the State Registry, to the State HIE, or through the State HIE to the State Registry, for purposes of public health reporting, or to my healthcare providers enrolled in the State Registry and/or State HIE for purposes of care coordination.

I further authorize the applicable Provider to (a) release my medical or other information, including my communicable disease (including HIV), mental health and drug/alcohol abuse information, to, or through, the State HIE to my healthcare professionals, Medicare, Medicaid, or other third-party payers as necessary to effectuate care or payment; (b) submit a claim to my insurer for the Services, and (c) request payment or authorized benefits be made on my behalf to the applicable Provider concerning the Services. I acknowledge that depending upon my state’s law, I may prevent, by using a state-approved opt-out form or, as permitted by my state law, an opt-out form (“Opt-Out Form”) furnished by the Provider: (a) the disclosure of my vaccination information by the Provider to the State HIE and/or State Registry; or (b) the State HIE and/or State Registry from sharing my vaccination information with any of my other healthcare providers enrolled in the State Registry and/or State HIE. The Provider will, if my state permits, provide me with an Opt-Out Form.

I understand that I may need to consent, depending on my state’s law, and to the extent so required, I hereby do consent by signing below to the Provider reporting my vaccination information to the State HIE, or through the State HIE and/or State Registry to the entities and for the purposes described in this Informed Consent Form. Unless I provide the Provider with a signed Opt-Out Form, I understand that my consent will remain in effect until I withdraw my permission and that I may withdraw my consent by providing a completed Opt-Out Form to the Provider and/or my State HIE, as applicable. I understand that even if I do not consent or if I withdraw my consent, my state’s laws may permit certain disclosures of my vaccination information to or through the State HIE as required or permitted by law. Photocopies/electronic transmissions/faxes of this consent and any signatures are to be considered as valid originals.

MY SIGNATURE BELOW INDICATES THAT I VOLUNTARILY AGREE TO ALL OF THE ABOVE AND THAT THE NATURE OF THIS CONSENT WAS EXPLAINED TO ME AND THAT I HAD THE OPPORTUNITY TO ASK ANY AND ALL QUESTIONS REGARDING THE ABOVE AND MY QUESTIONS HAVE BEEN ANSWERED TO MY SATISFACTION. I UNDERSTAND THE BENEFITS AND RISKS OF THE VACCINE AND I EXPRESSLY CONSENT, REQUEST, AND AUTHORIZE THE ADMINISTRATION OF THE VACCINE. I HAVE BEEN PROVIDED WITH THE CDC’S VACCINE INFORMATION SHEET(S) OR THE EMERGENCY USE AUTHORIZATION (EUA) PATIENT FACT SHEET CORRESPONDING TO THE VACCINE THAT I AM RECEIVING.
Signature*

Clear
Date Of Service*

MonthDayYear
Date
COVID-19 Vaccine Administered*
Vaccine Dose COVID-19*
Lot Number COVID-19*
Route & Site COVID-19 *
Given by*
Place of Service*
Should be Empty:

Screening Questionnaire

Patient Registration

Health Insurance Information

COVID-19 Vaccine Notice for Uninsured Patients

Vaccination Consent Form