COVID-19 Vaccine Consent Form

Is the patient 12 years or older?*

YesNo

Sorry you are not able to be vaccinated at our pharmacy at this time. Please check back soon. This will be updated as more people become eligible to be vaccinated at the pharmacy.

Select which dose you are receiving today:

1 st dose2nd dose3rd dose (immunocompromised)Booster Dose

Vaccine Recipient Name*

First NameMiddle NameLast Name

Vaccine Recipient Physical Address*

Street Address

Street Address Line 2

CityState Initials

Postal / Zip Code

Email

example@example.com

Date of Birth*

Gender *

Race*

Ethnicity*

Vaccine Recipient Phone Number*

Social Security #

Emergency Contact Name*

Relationship to Emergency Contact*

Phone Number of Emergency Contact*

COVID-19 Vaccine Screen Questions*

	Yes	No	Don't Know
1. Are you feeling sick today?
3a. Have you ever had an allergic reaction to acomponent of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures?
3b. Have you ever had an allergic reaction to Polysorbate?
3c. Have you ever had an allergic reaction to a previous dose of COVID-19 Vaccine?
4. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?(This would include a severe allergic reaction (e.g., anaphylaxis) that required treatment with epinephrine or EpiPen or that caused you to go to the hospital. It would also include and allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.)
5. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a component of COVID-19 vaccine, polysorbate, or any vaccine or injectable medication? This would include food, pet, environmental, or oral medication allergies.
6. Have you received any vaccine in the last 14 days?
7. Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19?
8. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? [note: monoclonal antibodies does not include antibiotics that you would be prescribed and filled at a pharmacy]
9. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
10. Do you have a bleeding disorder or are you taking a blood thinner?
11. Are you pregnant or breastfeeding?
12. Do you have dermal filers?
13. Do you have a history of myocarditis or pericarditis?
14. Do you have a history of Guillain-Barre Syndrome (GBS)?
15. Have you been diagnosed with Multisystem Inflammatory Syndrome after a COVID19 infection?

Have you ever received a dose of COVID-19 Vaccine

YesNo

COVID-19 Vaccine Manufacturer for the first dose received

Required if you selected "Yes" to #2

Date of most recent dose

Required if you selected "Yes" to #2

Consent (check each box below after reading and prior to signing the form)*

	Check each box
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet (the Moderna Fact Sheet is available after clicking submit), a copy of which I was provided with this 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 to the person named above, a minor for whom I represent that I am authorized to sign this Consent Form.
I understand that at this time, the Moderna COVID-19 vaccine and Pfizer COVID-19 vaccine requires 2 doses given 28/21 days apart depending on the manufacturer. If this is my second dose, I will bring my vaccine card with me to be completed.
I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.
I understand that I will be receiving the vaccination at no cost to me.

The vaccine is available to anyone no matter if insured or uninsured. Please check only one of the following.*

	Check one
If INSURED, check this box attesting to bringing in your prescription and medical insurance cards for your vaccine appointment. By selecting this, you are also authorizing the pharmacy to bill your insurance on your behalf for the immunization – understanding you will not incur any costs.
If UNINSURED, you must check this box to attest that the 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 number and state of issuanceDriver's license number and state of issuance

Signature

Clear