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Covid/Flu Vaccination Consent Form - Aging Well
Choose 1 or Both (COVID OR BOTH FLU and COVID)
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
Children under 16 must be accompanied by a parent or legal guardian over the age of 18.
Sex
*
Male
Female
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Choose 1 or Both
*
COVID
FLU
Attest Insured or Uninsured
*
I attest that I have health insurance, and I give Asthenis permission to retrieve my insurance information from my plan, or to call me to provide additional coverage information.
I attest that I am uninsured and am not enrolled in Medicaid, Medicare, or any commercial insurance.
Last 4 of Social Security Number
*
Name of Health Insurance Plan
Member ID Number
Screening Questions
Are you/the patient sick today?
Yes
No
Are you/the patient pregnant?
Yes
No
Have you/the patient received any vaccinations in the past 4 weeks?
Yes
No
Have you/the patient ever had a serious reaction to a vaccine or vaccine component?
Yes
No
Do you/the patient have cancer, leukemia, HIV/AIDS, or any other immune system conditions?
Yes
No
In the past year, have you/the patient received immune (gamma) globulin, blood/blood products, or an antiviral drug?
Yes
No
Consent
I have read, or have had read to me, the written information regarding the vaccine(s) being administered. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s) being administered and have received or reviewed a copy of a current Vaccine Information Sheet. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Asthenis, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s). I certify that I am at least 18 years old and hereby give my consent to Asthenis to administer the vaccine(s). If under 18 years old signature by parent or guardian is required. I agree to wait near the vaccination location for approximately 15 minutes for observation.
Signature
*
Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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Submit
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