COVID Vaccine Consent Form

MODERNA COVID Vaccine Consent Form

* Please fill out the required details below
If you have remaining questions, please call us at (423) 345-0333.
Our pharmacy is providing Moderna vaccine to individuals age 18+
Patient's Full Name:*

First NameMlLast Name
Date of Birth:*

MonthDayYear
Current Age:*
Social Security Number*
Phone Number:*
Email:*
Gender:*

MaleFemale
Ethnicity:*

Hispanic or LatinoNon Hispanic/LatinoUnknownPrefer not to answer
Race:*

African AmericanAmerican IndianAsianCaucasianNative Hawaiian/Other Pacific IslanderPrefer not to answerOther
Address:*

Street Address Line 2
Primary Care Doctor:
Doctor City/State:
Are you at least 18 years old?*

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

First DoseSecond Dose*Third Dose (must meet criteria below)
For 3rd Dose, check any conditions applying to you:*

Been receiving active cancer treatment for tumors or cancers of the bloodReceived an organ transplant and are taking medicine to suppress the immune systemReceived a stem cell transplant within the last 2 years or are taking medicine to suppress the immune systemModerate or severe primary immunodeficiency (such as DiGeorge syndrome, Wiskott-Aldrich syndrome)Advanced or untreated HIV infectionActive treatment with high-dose corticosteroids or other drugs that may suppress your immune responseN/A
When did you receive your first dose?*

MonthDayYear
Date
Section II. 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.)?
Have you received any vaccine in the past 14 days?
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 III. Appointment Scheduler
**Vaccine supply is limited. Please keep your appointment or call if you need to cancel or change it. Additionally, due to vaccine requirements; we may call you to see if you can come earlier, later or to a nearby location. If you miss an appointment, no doses will be held to guarantee your dose.**
Please pick a day and time for your vaccination
Section IV. Signatures

I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) (link), a copy of which I was provided with this Consent and Release. 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 of Person to Receive Vaccine & EUA/VIS*

Clear
I have received a copy of the notice of Privacy Practices. I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.
Signature of Acknowledgment of Notice of Privacy Practices:*

Clear
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
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
Enter Selected ID Info
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 and is accessed only via a secure, encrypted interface.
Should be Empty:

MODERNA COVID Vaccine Consent Form