Moderna COVID-19 Vaccine Appointment Scheduling and Consent Form

COVID-19 Vaccine Consent Form

In order to receive the vaccine, you must be in an active phase of the vaccination campaign. Visit the link below for more information on the most current vaccination eligibility in Kentucky. (https://govstatus.egov.com/kentucky-vaccine-survey)

Select an appointment time *

Vaccine Recipient Name *

First Name Middle Initial Last Name

Vaccine Recipient Physical Address

Street Address

Street Address Line 2

City State Initials

Postal / Zip Code

Date of Birth *

Gender

Male Female

Race

Vaccine Recipient Phone Number

Vaccine Recipient Email

example@example.com

Primary Care Provider Name

Emergency Contact Name

Relationship to Emergency Contact

Phone Number of Emergency Contact

COVID-19 Vaccine Screen Questions

Yes

No

1. Are you feeling sick today?

2. Have you ever received a dose of COVID-19 Vaccine?

3. 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?

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

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

6. 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.

7. Have you received any vaccine in the last 14 days?

8. Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19?

9. 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]

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

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

12. Are you pregnant or breastfeeding?

COVID-19 Vaccine Manufacturer for the first dose received (do not complete if you selected "no" to #2 above.)

Required if you selected "Yes" to #2

Date of first dose (do not complete if you selected "no" to #2 above.)

Required if you selected "Yes" to #2

Vaccine Eligibility *

Yes

No

1. Are you a resident of Kentucky?

2. Are you considered an essential worker according to the state of Kentucky?

3. Are you age 18 or older? (Currently we are administering the Moderna vaccine which is approved for patients 18 years and older.)

4. Are you age 16 or older with one or more conditions from the CDC highest risk for C19 list?

Consent for Vaccination(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 COVID-19 vaccine requires 2 doses given 21-28 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.

Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):

Clear

Date Signed

Date