ONEIRO Vaccine Consent Form

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Date of Birth*

Date

Gender*

We’d Appreciate Your Medicare or Medical ID (If Available)

Medicare- IdMedical-Id

Address*

Street Address

Street Address Line 2

CityState / Province

INSURANCE DETAILS*

Members ID

PCN

GROUPBIN

YOUR PHARMACY CHOICE

Name of Vaccine to be Administered

Are you feeling sick today?*

YesNoDon’t know

Have you been diagnosed with or tested positive for COVID-19 in the last 14 days?*

YesNoDon’t know

In the past 14 days have you been identified as a close contact to someone with COVID-19?*

YesNoDon’t know

Do you have a history of allergic reaction or allergies to latex, medications, food or vaccines (examples: polyethylene glycol, polysorbate, eggs, bovine protein, gelatin, gentamicin, polymyxin, neomycin, phenol, yeast or thimerosal)?*

YesNoDon’t know

Have you ever had a reaction after receiving a vaccination, including fainting or feeling dizzy?*

YesNoDon’t know

Have you ever had a seizure disorder for which you are on seizure medication(s), a brain disorder, Guillain-Barré syndrome (a condition that causes paralysis) or other nervous system problem?*

YesNoDon’t know

Have you received any vaccinations or skin tests in the past eight weeks?*

YesNoDon’t know

Have you ever received the following vaccinations?*

YesNoDon’t know

Do you have any chronic health condition such as cancer, chronic kidney disease, immunocompromised, chronic lung disease, obesity, sickle cell disease, diabetes, heart disease?*

YesNoDon’t know

For women: Are you pregnant or considering becoming pregnant in the next month?*

YesNoDon’t know

For COVID-19 vaccine only: Have you been treated with antibody therapy specifically for COVID-19 (monoclonal antibodies or convalescent plasma)?*

YesNoDon’t know

Do you have a condition that may weaken your immune system (e.g., cancer, leukemia, lymphoma, HIV/AIDS, transplant)?*

YesNoDon’t know

Are you currently on home infusions, weekly injections such as Humira® (adalimumab), Remicade® (infliximab) or Enbrel®(etanercept), high-dose methotrexate, azathioprine or 6-mercaptopurine, antivirals, anticancer drugs or radiation treatments?*

YesNoDon’t know

Are you currently taking high-dose steroid therapy (prednisone > 20mg/day or equivalent) for longer than 2 weeks?*

YesNoDon’t know

Have you received a transfusion of blood or blood products or been given a medication called immune (gamma) globulin in the past year?*

YesNoDon’t know

Do you have a history of thymus disease (including myasthenia gravis, DiGeorge syndrome or thymoma), or had your thymus removed? (yellow fever only)*

YesNoDon’t know

Do you have a history of thrombocytopenia or thrombocytopenic purpura? (MMR only)*

YesNoDon’t know

Have you consumed any food or drink in the last hour? (Vaxchora® only)*

YesNoDon’t know

Have you taken antibiotics in the last 14 days or antimalarials in the last 10 days? (Vaxchora® only)*

YesNoDon’t know

Please indicate your health conditions below

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.

Signature*

Date