COVID Vaccine Consent Form

If you have remaining questions, please call us at 641-664-3100

Section II. Personal Information

Patient's Full Name:*

First NameMlLast Name

Date of Birth:*

Age:

Phone Number:*

Gender:*

MaleFemale

Address:

Street Address Line 2

Primary Care Doctor:

Doctor City/State:

What dose of COVID-19 vaccine will this be?*

First DoseSecond Dose

Section III. Questionnaire for Immunization

Please select the correct option below:

	Yes	No	Don't know or N/A
COVID-19 Screening Questions: In the past two weeks, have you tested positive for COVID-19 or are you currently being monitored for COVID-19?
In the past two weeks, have you had a known exposure with anyone who tested positive for COVID-19?
Have you had a new onset of fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, nausea, vomiting, or diarrhea?
Questionnaire for Immunization: Do you feel sick today?
Do you have an allergy to medications, foods, or any vaccines (eggs, gelatin, thimerosal, neomycin, gentamicin, latex, aluminum, preservatives, baker's yeast, etc.)?
Do you carry an EpiPen?
Have you received COVID-19 monoclonal antibodies or convalescent plasma in the last 90 days?
Have you ever had a serious reaction or fainted after receiving any vaccination?
Have you ever had a seizure, brain disorder, or Guillain-Barre Syndrome?
For women: Are you pregnant or are you planning on becoming pregnant during the next month?

Please specify the allergy from Q2:

Section IV. Signature

I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) available at wellshometowndrug.com. 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 and Release.

Signature

Insurance Authorization-Please Bring Your Insurance Card to Your Appointment

I authorize the pharmacy to bill my insurance on my behalf for the immunization

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 health benefit plan

If you don't have insurance, in order to have your vaccine administration fee paid for by the United States Health Resources & Services Administration's COVID-19 Program for uninsured patients, please select to provide one of the following:*

Social Security NumberState identification number and state of issuanceDriver's license number and state of issuance

Social Security Number

State identification number and state of issuance

Driver's license number and state of issuance

By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential. You will receive a thank you page which means your submission was a success.

Email-For Confirmation

example@example.com

COVID Vaccine Consent Form - Wells Hometown Drug