COVID-19 Vaccine Consent

Name*

First NameLast Name

Social Security Number (SSN)

Optional

Date of Birth (mm/dd/yyyy)*

Cell Phone*

Please enter a valid phone number.

May we leave a voicemail?

YesNoN/A

Alt. Phone*

Please enter a valid phone number.

May we leave a voicemail?

YesNoN/A

Email Address

example@example.com

1) Are you feeling sick today?*

YesNo

2) Have you ever received a dose of COVID-19 vaccine?*

YesNo

If yes, how many doses:

If yes, which vaccine product did you receive?

PfizerModernaJohnson & JohnsonAnother Product

If you received another product, what was it?

3) Have you ever had a SEVERE reaction? (e.g. anaphylaxis to something? For example, a reaction for which you were treated with epinephrine or EpiPen, or for which you had to go to the hospital?)

YesNo

Was the severe allergic reaction after receiving a COVID-19 vaccine?

YesNo

Was the severe allergic reaction after receiving another vaccine or another injectable medication?

YesNo

4) Are you allergic to Neomycin?*

YesNo

5) Are you able to eat lightly cooked eggs (ex. scrambled) without an allergic reaction?*

YesNo

6) Have you ever had a reaction to latex?*

YesNo

7) Are you allergic to gelatin?*

YesNo

8) Do you have a bleeding disorder or are you taking blood thinner?*

YesNo

9) Have you received passive antibody therapy as treatment for COVID-19?*

YesNo

I have reviewed the COVID-19 EUA fact sheet. I have had a chance to ask questions, which were answered to my satisfaction. I understand the benefits and risks of the COVID-19 vaccine and I request that the vaccine be given to me or to the person named above, for whom I am authorized to make this request.

Signature (Signature of person to receive vaccine or Legally Empowered Representative)*

Date*

F1051 / APPROVED FOR USE

COVID-19 VACCINE CONSENT FORM

Please fill out any/all contact methods.