COVID Vaccine Consent Form

COVID Vaccine Consent Form - Medicap VA Ave

* Please fill out the required details below
You are signing up for a MODERNA COVID-19 BIVALENT BOOSTER VACCINE. For information on this vaccine click the image above to be directed to the EUA (Emergency Use Authorization) form provided by the manufacturer. If you are in need of a Pfizer Covid-19 Vaccine please stop and find another location that offers that vaccine. If you have remaining questions, please call us at (540)434-7455.
**Please keep your appointment or call if you need to cancel or change it. If you miss an appointment, no doses will be held to guarantee your dose.**
Appointment Date and Times listed below. Only dates and times listed in blue are available to be selected. If all times are listed in gray then none are currently available. Check back at a later time as it will be updated daily.*
Section I. Personal Information
Patient's Full Name:*

First NameMlLast Name
Date of Birth:*

MonthDayYear
Age:*
Phone Number:*
Gender:*

MaleFemale
Ethnicity:*

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

Black or African AmericanAmerican Indian or Alaska nativeAsianWhiteNative Hawaiian/Other Pacific IslanderPrefer not to answer
Email
example@example.com
Address:*

Street Address Line 2
Primary Care Doctor:
Doctor City/State:
What dose of COVID-19 vaccine will this be?*

BOOSTER (THIS WILL BE THE NEW BIVALENT VACCINE)
Are you Immunocompromised?*

YesNo
When did you receive your MOST RECENT dose?*

MonthDayYear
Date
Section II. Questionnaire for Immunization

Please select the correct option below:*

	Yes	No	Don't know or N/A
Do you feel sick today?
Have you ever had an allergic reaction to 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, which is found in some vaccines, film coated tablets, and intravenous steroids?
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 or injectable medication?
Have you ever had a severe allergic reaction to something other than a component of Covid-19 Vaccine, or any vaccine or injectable medication?
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?
Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
Do you have a bleeding disorder or are you taking a blood thinner?
Are you pregnant or breastfeeding?
Do you have dermal fillers?

Please list severe allergies
Section III Signatures

I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA), a copy of which I viewed by clicking on the image above of the vaccine I wish to receive. 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 Click here for 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
Please take or upload pictures of front & back of insurance card for billing purposes

Browse Files

Cancelof
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
Social Security Number
State identification number and state of issuance
Driver's license number and state of issuance
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.
Vaccine Date Administered Vaccine Lot Exp Dosage Injection site

__/__/2021 0.5ml R / L Arm

0.25ml

Signature: _____________________________________________________________
Should be Empty:

COVID Vaccine Consent Form - Medicap VA Ave