COVID-19 Vaccine 2024-25 Consent and Questionnaire

Spikevax COVID-19 2024-25 Vaccine Consent and Questionnaire
26A Picotte Dr.

Albany, NY 12208

518-435-2315

COVID-19 Administration Form

This form is for the Spikevax (Moderna) Vaccine for everyone over 12 years old. (NOT the Pediatric Dose).

Please read the COVID-19 VIS
Date*

MonthDayYear
Date
Name

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Gender (M/F)*
Phone*
Email
example@example.com
Home address*
City*
State*
Zip*
Race*
Ethnicity*
Insurance Plan Name*
ID#: If you have Medicare please enter your Medicare ID number or last 4 digits of your SSN. If you have Medicaid please enter your Medicaid ID number *
BIN
PCN
RX Group #
Primary Care Provider/Doctor Name
Primary Care Provider's Phone
1. Do you currently feel sick?*

YesNoUnsure
2. Have you been sick in the last 2 weeks?*

YesNoUnsure
3. Do you currently have a fever?*

YesNoUnsure
4. Do you have any health conditions (e.g diabetes, heart disease, asthma, etc.)?*

YesNoUnsure
If yes, then please list:
5. Have you received a COVID-19 vaccine before?*

YesNoUnsure
6. Was your last COVID-19 Vaccine dose more than 2 months a go?*

YesNoUnsure
7. Have you had a reaction to the vaccine before?*

YesNoUnsure
If yes, what was the reaction:
8. Do you have any allergies to medications or foods?*

YesNoUnsure
If yes, please list:
9. Are you allergic to thimerosal?*

YesNoUnsure
10. Are you currently pregnant?*

YesNoUnsure
11. Are you a health care worker?*

YesNoUnsure
12. Have you ever had Guillain-Barre Syndrome?*

YesNoUnsure
13. Do you have a blood-clotting disorder?*

YesNoUnsure
14. Have you experienced any blood-clotting issues from a previous vaccination?*

YesNoUnsure
15. Are you taking any blood-thinning medications?*

YesNoUnsure
Please read carefully and sign below.
I, the undersigned, have read or had explained to me the emergency use authorization (EUA). I understand that it is not possible to predict all side effects or complications associated with receiving vaccination I understand the risks and benefits associated with the COVID-19 vaccine and have had any questions satisfactorily answered. I voluntarily request that the vaccine be given to me or for the aforementioned person for whom I am authorized to make this request.
Signature*

Clear
Print Name*
Date*

MonthDayYear
Date
Appointment*
Should be Empty:

Spikevax COVID-19 2024-25 Vaccine Consent and Questionnaire