Prevaccination Checklist for COVID-19 Vaccines
The following questions will help us determine if there is any reason you should not get the COVID-19 vaccine today. If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions may be asked. If a question is not clear, please ask your healthcare provider to explain it.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Cell phone number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Age
*
Weight (in pounds)
*
Are you feeling sick today?
*
Yes
No
Don't know
Have you ever received a dose of COVID-19 vaccine?
*
Yes
No
Don't know
Have you ever had a severe allergic reaction (e.g. anaphylaxis) to a COVID-19 vaccine component such as polyethylene glycol (PEG) or polysorbate? A reaction for which you were treated 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 wheezing.
*
Yes
No
Don't know
Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?
*
Yes
No
Don't Know
Have you received another vaccine in the last 14 days?
*
Yes
No
Don't know
Have you ever had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?
*
Yes
No
Don't know
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Check all that apply to you:
Am a female between ages 18 and 49 years old
Had a severe allergic reaction to something other than a vaccine or injectable therapy such as food, pet, venom, environmental or oral medication allergies
Had COVID-19 and was treated with monoclonal antibodies or convalescent serum
Diagnosed with Multisystem Inflammatory Syndrome (MIS-C or MIS-A) after a COVID-19 infection
Have a weakened immune system (i.e., HIV infection, cancer)
Take immunosuppressive drugs or therapies
Have a bleeding disorder
Take a blood thinner
Have a history of heparin-induced thrombocytopenia (HIT)
Am currently pregnant or breastfeeding
Have received dermal fillers
Insurance Information
*
Please indicate type of insurance (whether it is Medicare, Medi-Cal or private coverage). Insurance status does not change your eligibility for the vaccine.
Consent
I certify that I am: (a) the patient and at least 18 years of age; (b) the parent or legal guardian of the patient and confirm that the patient is at least 16 years of age; or (c) authorized to consent for vaccination for the patient named above. Further, I hereby give my consent to Santa Clarita Pharmacy to administer the COVID-19 vaccine.
I understand that this product has not been approved or licensed by FDA, but has been authorized for emergency use by FDA, under an EUA to prevent Coronavirus Disease 2019 (COVID-19) for use in individuals 12 years os age and older (Pfizer vaccine) or 18 years of age and older (Moderna or Janssen vaccine); and the emergency use of this product is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of the medical product under Section 564(b)(1) of the FD&C Act unless the declaration is terminated or authorization revoked sooner.
I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccine(s). I understand the risks and benefits associated with the above vaccine and have received, read and/or had explained to me the Emergency Use Authorization Fact Sheet on the COVID-19 vaccine I have elected to receive. I also acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction.
I acknowledge that I have been advised to remain near the vaccination location for approximately 15 minutes after administration for observation; and for 30 minutes if I have a history of anaphylaxis from any cause. If I experience a severe reaction, I will call 9-1-1 or go to the nearest hospital.
On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless Family Matters DPC, and their staff, associates, successors, divisions, affiliates, subsidiaries, officers, directors, contractors and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the vaccine listed above.
I acknowledge that: (a) I understand the purposes/benefits of CA-SIIS, California's immunization registry and (b) will include my personal immunization information in CA-SIIS and my personal immunization information will be shared with the Centers for Disease Control (CDC) or other federal agencies.
I acknowledge receipt of the Notice of Privacy Rights.
By signing, I have completed this form to the best of my knowledge and consent to the agreement as written and receipt of vaccine.
Signature of Patient or Authorized Representative
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Print Name (if someone other than patient to receive vaccine)
First Name
Last Name
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