Vaccine Consent & Screening Form

Vaccine Consent & Screening Form

Complete your details and pre-vaccination screening, then review and sign your consent for vaccination.
Patient Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sex
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Vaccine Requested
Insurance Information (if applicable)
Do you have any allergies? If yes, please list.
Are you currently ill or experiencing any symptoms of illness?
Have you ever had a serious reaction to a vaccine?
Have you ever fainted after receiving an injection?
Do you have any relevant medical conditions (e.g., chronic illnesses, immune disorders)?
Are you taking any medications that affect your immune system (e.g., steroids, immunosuppressants)?
Are you pregnant or could you be pregnant?

Pre-vaccination Screening Questions

Rows	Yes	No
Are you feeling sick today?
Have you received any other vaccines in the past 4 weeks?
Have you ever had a severe allergic reaction to anything?
Do you have a bleeding disorder or are you taking a blood thinner?
Do you have a weakened immune system?