COVID-19 Vaccine Consent

  • COVID-19 VACCINE CONSENT FORM

  • Date of Birth (mm/dd/yyyy)*
     / /

  • Please fill out any/all contact methods.

  • Format: (000) 000-0000.
  • May we leave a voicemail?
  • Format: (000) 000-0000.
  • May we leave a voicemail?
  • 1) Are you feeling sick today?*
  • 2) Have you ever received a dose of COVID-19 vaccine?*
  • If yes, which vaccine product did you receive?
  • 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?)
  • Was the severe allergic reaction after receiving a COVID-19 vaccine?
  • Was the severe allergic reaction after receiving another vaccine or another injectable medication?
  • 4) Are you allergic to Neomycin?*
  • 5) Are you able to eat lightly cooked eggs (ex. scrambled) without an allergic reaction?*
  • 6) Have you ever had a reaction to latex?*
  • 7) Are you allergic to gelatin?*
  • 8) Do you have a bleeding disorder or are you taking blood thinner?*
  • 9) Have you received passive antibody therapy as treatment for COVID-19?*

  • 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.

  • Date*
     / /

  • F1051 / APPROVED FOR USE

  • Please note that for privacy reasons, we are unable to respond via email to questions regarding specific health concerns.

  • Should be Empty: