COVID Consent

COVID Vaccine Consent Form
Patient Age Range
- Parent/Guardian Name
  
  First NameMiddle NameLast Name
- Relationship to Student
- Name of School
- Campus
  Example: High School, Middle School, Elementary School
- Grade
- Homeroom Teacher
- Site/Facility
- Full, Legal Name (First Name, Middle Initial, Last Name)
  
  First NameMiddle InitialLast Name
- Social Security Number (For Superior Medicaid Only)
- Birth Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit year
- Age
- Sex
- Race
- Ethnicity
- Email Address
  example@example.com
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Primary Phone #
- Secondary Phone #
- The current health care laws require us to bill your insurance company for the vaccine. There will be no out of pocket expense for those insured.
- Insurance Company
- Member ID
- Group #
- Policy Holder's Name
- Policy Holder's Date of Birth
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit year
- THE COVID VACCINE YOU RECEIVED WILL BE REPORTED TO IMMTRAC2 WITHIN 24 HOURS OF ADMINISTRATION. IF YOU HAVE ANY HEALTH QUESTIONS, PLEASE CONTACT YOUR PRIMARY CARE PHYSICIAN OR CALL AURORA CONCEPTS AT 936-598-3296 TO SPEAK TO A NURSE.
- CHILD AND PEDIATRIC PATIENTS MAY ONLY RECEIVE THE PFIZER COVID VACCINATION.
- Vaccine Manufacturer
- Vaccine to be given
- Original Vaccination
  Select the initial vaccination type you received.
- 1st Vaccination Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearEnter the date of your first vaccination dose.
- 2nd Vaccination Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearEnter the date of your second vaccination dose. If you received the Jansen Vaccine, please enter the same date as your 1st vaccination.
- Pediatric Vaccination
- Signer's Name
- Signature
  
  Use your mouse or finger to sign
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit year
- Should be Empty:

COVID Vaccine Consent Form