COVID-19 Vaccine Consent Form

Patient Name*

First NameMiddle InitialLast Name

Date of Birth*

Date

Age*

Gender*

MF

Address*

Address

Street Address Line 2

City, State, Zip

County

Phone

Email

SS#*

Ethnicity

Hispanic or LatinoNon-Hispanic or Latino

Mother's Maiden Name

Used for the Texas Department of Health Immunization Tracking

Hispanic, Latino, or Spanish*

Primary Physician Name

First NameLast NameSuffix

Physician Phone

Employer

Check which box(es) describes you:*

Are you feeling sick today?*

YESNO

Have you already received a COVID 19 Vaccine?*

YESNO

If yes, which vaccine product?

Name of other product

Date of 1st COVID-19 Vaccine

Date

Have you ever had a severe allergic 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 reaction to any vaccine or injectable medication?*

YESNO

Do you carry an EpiPen® (or its equivalent)?*

YESNO

Are you allergic to polysorbate or polyethylene glycol or any components of the vaccine? (Powder laxative)*

YESNO

Do you have a moderate or severe weakened immune system caused by something such as cancer, HIV infection, organ transplant, stem cell transplant or a similar condition or do you take immunosuppressive drugs or therapies?*

YESNO

Do you have a history of Guillian-Barre' syndrome?

YesNo

Have you had myocarditis (inflammation of the heart muscle) or pericarditis (inflammation of the lining of the heart)?

YesNo

Have you had a positive test for COVID-19 or have you been diagnosed with COVID-19 in the last 90 days?*

YESNO

If yes, when?

Date

Have you had immune globulin, monoclonal antibodies, convalescent serum, or a blood transfusion in the past 90 days (3 months)?*

YESNO

In the past 2-14 days have you experienced fever or chills, cough, shortness of breath, fatigue, muscle/ body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea?*

YESNO

In the past 2-14 days are you aware of being exposed to someone who tested positive for COVID-19?*

YESNO

Are you pregnant or planning to be pregnant in the next 3 months?

YESNO

Are you breastfeeding?

YESNO

Have you received another vaccine or injection in the past 14 days?*

YESNO

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

YESNO

List any drug allergies

I reviewed a copy of the Vaccination FDA Emergency Use Authorization (EUA) and have had the opportunity to ask questions about the risks and benefits of this vaccination.*

YESNO

Moderna COVID-19 Vaccine EUA

Moderna COVID-19 Vaccine EUA

https://www.fda.gov/media/144638/download

Pfizer COVID-19 Vaccine EUA for 12 Years of Age and Older

https://www.fda.gov/media/153716/download

Pfizer COVID -19 Vaccine EUA for 5 Through 11 Years of Age

https://www.fda.gov/media/153717/download

J&J Janssen COVID-19 Vaccine EUA

https://www.fda.gov/media/146305/download

Novavax COVID-19 Vaccine EUA

https://www.fda.gov/media/159898/download

Pfizer COVID-19 Vaccine Fact Sheet

Janssen COVID-19 Vaccine EUA

I understand common side effects may include injection site redness, swelling, or pain, swelling of lymph nodes in arm of injection, aches or muscle pain, joint pain, fatigue, headache, shivering or chills, fever, gastrointestinal symptoms, malaise, and that the benefits include disease prevention.*

YESNO

I am aware of reports of rare Thrombosis with Thrombocytopenia 1-2 weeks following the Janssen vaccine. I am aware of an increased risk of Guillain-Barre’ syndrome 42 days following vaccination with the Janssen or Novavax vaccine.

YesNo

I understand that it is recommended that I stay on location 15-30 minutes following the injection.*

YESNO

This vaccination record will be reported to the Texas Department of Health Immunization Tracking Service and primary healthcare providers.*

YESNO

I consent for the vaccination to be administered to me and for the immunizer to initiate the emergency medical plan if necessary due a reaction to the vaccination.*

YESNO

I am aware of the potential risks and side effects of the vaccine as described in the literature as well as the risk of the disease it prevents. I hereby waive any liability towards Valmed Home Health & Pharmacy Solutions and/or its administering employee of potential adverse effects associated with administration of the vaccine. I authorize the release of any medical or other information necessary to process the claim and I hereby assign all insurance, Medicare, Medicaid and other third-party payors' benefits for services rendered. I have been offered the HIPAA Privacy Policy.

Date*

Date

Signature Person receiving vaccine or Parent or Guardian, if recipient is unable to sign.*

Relationship (if not the person receiving the vaccine is unable to sign)

COVID-19 Vaccine Consent Form

Past Medical History

Consent to Immunize