COVID-19 Vaccination Consent Form

Name *

First Name Last Name

Date of Birth *

Date

Age *

Phone Number *

Please enter a valid phone number.

Email *

example@example.com

Gender *

Male Female

Ethnicity *

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

Race *

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

Height (inches) *

Weight (lbs) *

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Primary Care Doctor *

Doctor City/State *

Street Address

Street Address Line 2

City State / Province

Mother's Maiden Name *

Emergency Contact Name *

Relationship to Emergency Contact *

Emergency Contact Phone Number *

Please enter a valid phone number.

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? *

Pfizer Moderna Other

We are sorry but at this time we are only able to provide the second dose for the Pfizer vaccine.

Please select the correct option below: *

Yes

No

Don't know or N/A

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, headaches, new loss of taste or smell, sore throat, nausea, vomiting, or diarrhea?

Are you feeling sick today?

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?

Have you ever had an allergic reaction* to polysorbate?

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

Have you ever had an allergic reaction* to another vaccine (other than COVID-19 vaccine) or an injectable medication?

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.

Do you carry an EpiPen®?

Have you received any vaccine in the last 14 days?

Have you ever had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?

Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?

Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?

Have you ever had a seizure, brain disorder, or Guillain-Barre Syndrome?

Do you have a bleeding disorder or are you taking a blood thinner?

For women: Are you pregnant or breastfeeding, or are you planning to become pregnant in the next month?

*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.

I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA), 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 and for whom I am authorized to sign this Consent and Release.

Signature of Person to Receive Vaccine & EUA, or Parent/Guardian, if Recipient is a Minor *

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 Acknowledgement of Notice of Privacy Practices *

Clear

Please indicate type of insurance *

Medicaid Medicare Part B Private Insurance No Insurance

Medicaid Provider *

Policy/Member ID *

Medicaid # *

Medicaid Group # *

Medicare Subscriber ID *

Responsible Party *

Policy Holder's Date of Birth *

Date

Insurance Provider *

Subscriber ID *

Bin # *

PCN *

Group # *

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

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 Number State identification number and state of issuance Driver'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 *

*

I understand that after submitting this form I must schedule my vaccination, and if I do not complete this second form, the pharmacy cannot guarantee a vaccine will be available for me.

*

I agree to wait with the immunizing team 15-30 minutes after my vaccination has been administered.

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.

I have reviewed Patient Information and Questionnaire for Immunization with the patient prior to administering the vaccine, and they have indicated that all answers are accurate as of the day of administration.

The patient did not have an adverse reaction after 15 minutes

Blood Pressure

Temperature

Pulse

File Upload

Vaccine Manufacturer

Pfizer Moderna Other

Time Removed from -80 C

Hour Minutes

AM/PM Option

Date Removed

Date

Vaccine Lot Number

Expiration Date

Date

Dosage

Injection Site

Signature of Licensed Administrator

Clear

Name of Licensed Administrator

First Name Last Name

Date Administered

Date

Time Administered

Hour Minutes

AM/PM Option

COVID-19 Vaccination Consent Form

Personal Information

Immunization Questionnaire

Signatures

Insurance

For Pharmacy Use Only