COVID Vaccine Consent Form

Vaccine supply is limited. Filling out this form will not guarantee an appointment in the order in which it was received. Vaccines are prioritized to those who are most vulnerable. Moderna vaccine is for 18 years and older, Pfizer vaccine is for 16 years and older. Please call Tribal Health at (406) 745-3525 with questions.

Personal Information

Patient's Full Name: *

First Name Ml Last Name

Date of Birth: *

Age: *

Phone Number: *

Alternate Phone Number: *

Ethnicity: *

Hispanic or Latino Non Hispanic/Latino Unknown Prefer not to answer

Gender: *

Male Female

Race: *

African American American Indian Asian Caucasian Native Hawaiian/Other Pacific Islander Prefer not to answer

Address: *

Street Address Line 2

Are you eligible for services at Tribal Health? *

Yes No I don't know

I am eligible for a COVID-19 vaccination because I am: *

70 years or older An American Indian or other person of color who may be at elevated risk for COVID-19 complications 16-69 years of age with a high-risk medical conditions (examples include: diabetes, heart disease, chronic lung disease, chronic kidney disease, chronic liver disease, undergoing cancer treatment, immunocompromised, organ transplant recipient, HIV/AIDS) Health care worker or staff/resident of a long-term care facility

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

First Dose Second Dose

When did you receive your first dose? *

Date

Which vaccine did you receive for your first dose? *

Pfizer Moderna

*

Yes

No

Don't know or N/A

Questionnaire for Immunization:
1. Do you feel sick today?

2. 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.
(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 an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.)

3. Have you ever had an allergic reaction (e.g. anaphylaxis) to polysorbate?

4. Have you ever had an allergic reaction to a previous dose of COVID-19 vaccine?

5. Have you ever had a severe allergic reaction to something else? (This could include food, pet, environmental, or medications)

6. Have you received another vaccine in the last 14 days?

7. Have you had a positive test for COVID-19 or has a doctor 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?

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?

Please specify the allergy from Q4:

Signatures

Please read this statement and the Emergency Use Authorization (EUA). By signing below, you are agreeing that you have had a chance to ask questions and were provided satisfactory answers and you believe the benefits outweigh the risks of the COVID-19 vaccine to be given today. Signing this form verifies the patient or guardian has read the COVID-19 Vaccine Fact Sheet and authorizes the patient named on this form to receive the COVID-19 vaccine.

Signature of Person (Parent/Guardian) to Receive Vaccine & EUA/VIS *

Clear

I authorize Tribal Health to collect and enter immunization records for the listed patient into the Department of Public Health and Human Services Immunization Information records (ImMTrax). ImMTrax is a confidential computer system that contains immunization records. I understand that information in the registry may be released to a public agency, the patient’s healthcare provider(s), and other facilities such as schools. I understand that I can revoke my authorization and have my record removed at any time by contacting my local Health Department. By signing below, I agree to allow immunization information to be entered into ImMTrax.

Signature of Acknowledgment of imMTrax registry:

Clear

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.

CSKT Tribal Health COVID Vaccine Request Form