COVID-19 Vaccine Registration Form

COVID-19 Vaccine Registration Form

THE MODERNA OR JOHNSON AND JOHNSON COVID-19 VACCINE TO PREVENT CORONAVIRUS DISEASE 2019(COVID-19) IN INDIVIDUALS 18 YEARS OF AGE AND OLDER
Name *

First Name Last Name
Birth Date *

Month Day Year
Date
Gender *

Female Male
Phone Number *
Please enter a valid phone number.
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Race *
Ethnicity *
Appointment *
Insurance Company
Insurance Prescription ID
Insurance Rx Group Number
Insurance BIN number
Insurance PCN (if applicable)
Social Security Number *

Consent: please read and check each box before submitting your 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. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine be given to me or to the person named above, a minor for whom I represent and am authorized to sign this consent form. (A link to a copy of the EUA Fact Sheet will be available at the bottom of this form).

I understand the Johnson & Johnson/Jansen vaccine is a one dose vaccine but, if I am receiving either the Pfizer or Moderna COVID-19 vaccine, it requires 2 doses given 21 and 28 days apart, respectively. 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 vaccine at no cost to me, but will present my insurance card(s) and/or SSN for administration/billing purposes.

Signature of patient to receive vaccine or authorized representative of patient to receive vaccine. By signing, I confirm that all information provided is correct *

Clear
Date Signed *

Month Day Year
Date
EMERGENCY USE AUTHORIZATION (EUA) OF THE MODERNA COVID-19 VACCINE TO PREVENT CORONAVIRUS DISEASE 2019 (COVID-19) IN INDIVIDUALS 18 YEARS OF AGE AND OLDER
Should be Empty: