Moderna/Pfizer COVID-19 Vaccine Consent Form

Cave's Drug Store COVID-19 Vaccine Consent Form
Name*

First NameLast Name
Birth Date

MonthDayYear
Sex*

MaleFemaleOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Race*

WhiteBlack or African AmericanAsianAmerican Indian or Alaskan NativeNative Hawaiian or Other Pacific IslanderOtherUnknown
Ethnicity*

Non-hispanic or LatinoHispanic or LatinoUnknown
Primary Care Provider Name:
Emergency Contact Name
Emergency Contact Phone Number:
Are you feeling sick today?*

YESNO
Have you ever received a dose of COVID-19 Vaccine?*

YESNO
Have you ever had an allergic reaction to a component of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures, polysorbate, or a previous dose of COVID-19 vaccine?*

YESNO
Have you ever had an allergic reaction to another vaccine or an injectable medicine?*

YESNO
Have you ever had a severe allergic reaction (e.g. anaphylaxis) to something other than vaccines or injectables, including food, pet, environmental?*

YESNO
Have you received any vaccine in the past 14 days?*

YESNO
Have you ever had a positive test for COVID-19 or has a healthcare provider ever told you that you had COVID-19?*

YESNO
Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as a treatment for COVID-19 in the last 90 days?*

YESNO
Are you pregnant or breastfeeding?

YESNO
Consent: I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet, a copy of which I was provided with the consent form. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or the person named above, a minor, for whom I represent that I am authorized to sign this consent form.*

I Agree
I understand that at this time, the COVID-19 vaccine requires 2 doses given 28 days apart. If this is my second dose, I will bring my vaccine card with me to be completed.*

I Agree
I agree to stay in the vaccine administration area for 15 minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.*

I Agree
I understand that I will be receiving the vaccine at no cost to me.*

I Agree
If insured, please bring your prescription and medical insurance cards for your vaccine appointment. I authorize the pharmacy to bill my insurance on my behalf for the administration of the immunization- understanding I will not incur any costs.

I Agree
If UNINSURED, you must check the box below to attest that the following information is true and accurate:

I do not have any insurance, including but not limited to, Medicare, Medicaid or any other private or government-funded benefit plan.
For uninsured patients, please select at least one of the following that you will bring with you to your appointment

Social Security numberState identification numberDriver's license number
Signature of Person to Receive Vaccine & EUA/VIS (or Signature of Parent/Guardian if Patient is < 18 years old.*

Clear
Date*

MonthDayYear
Date
This consent form is valid for 12 months from date signed.
Should be Empty:

Cave's Drug Store COVID-19 Vaccine Consent Form