86th COVID-19 Vaccine Consent Form

COVID-19 Vaccine Consent Form
Vaccine Recipient Name*

First NameMiddle NameLast Name
Vaccine Recipient Physical Address*

Street Address

Street Address Line 2

CityState Initials

Postal / Zip Code
Date of Birth*

MonthDayYear
Phone Number
Please enter a valid phone number.
Email
example@example.com
Current Gender ID*
Sex Assigned at Birth
Race*
Ethnicity
Parent/Guardian/Surrogate (if applicable)
Preferred Language

Primary Insurance
Primary Insurance Name
Primary Insurance ID #
Primary Insurance Group #
Subscriber Name/DOB
Subscriber Relation to Patient
Primary Insurance Phone #

Secondary Insurance
Secondary Insurance Name
Secondary Insurance ID #
Secondary Insurance Group #
Subscriber Name/DOB
Subscriber Relation to Patient
Secondary Insurance Phone #

Have you received a previous dose of the COVID-19 vaccine? If yes, which vaccine?*

Additional Questions*

	Yes	No	Unknown
1. Are you feeling sick today?
2. In the last 10 days, have you had a COVID-19 test because you had symptoms and are still awaiting your test results or been told by a health care provider or health department to isolate or quarantine at home due to COVID-19 infection, exposure or travel?
3. Have you been treated with antibody therapy or convalescent plasma for COVID-19 in the past 90 days (3 months)
4. Have you ever had an immediate allergic reaction (e.g., hives, facial swelling, difficulty breathing, anaphylaxis) to vaccine, injection or shot or to any component of the COVID-19 vaccine, or a severe allergic reaction (anaphylaxis) to anything?
5. Have you had any vaccines the the past 14 days? (2 weeks) including flu shot?
6. Are you pregnant or considering becoming pregnant?
7. Do you have cancer leukemia, HIV/AIDS, a history of autoimmune disease or any other condition that weakens the immune system?
8. Do you take any medications that affect your immune system, such as cortisone, prednisone or other steroids, anticancer drugs, or have you had any radiation treatments?
9. Do you have a bleeding disorder or are you taking a blood thinner?

Emergency Use Authorization

The FDA has made the COVID-19 vaccine available under an emergency use authorization (EUA). The EUA is used when circumstances exist to justify the emergency use of drugs and biological products during an emergency, such as the COVID-19 pandemic. This vaccine has not undergone the same type of review as an FDA-approved or cleared product. However, the FDA’s decision to make the vaccine available is based on the totality of scientific evidence available, showing that known and potential benefits of the vaccine outweigh the known and potential risks.

Consent

I have read, or had explained to me, the information sheet about the COVID-19 vaccination. I understand that if my vaccine requires two doses, I will need to be administered (given) two doses of this vaccine in order for it to be effective. I have had a chance to ask questions which were answered to my satisfaction (and ensured the person named above for whom I am authorized to provide surrogate consent was also given a chance to ask questions). I understand the benefits and risks of the vaccination asdescribed.

I request that the COVID-19 vaccination be given to me (or the person named above for whom I am authorized to make this request and provide surrogate consent). I understand there will be no cost to me for this vaccine. I understand that any monies or benefits for administering the vaccine will be assigned and transferred to the vaccinating provider, including benefits/monies from my health plan, Medicare or other third parties who are financially responsible for my medical care. I authorize release of all information needed (including but not limited to medical records, copies of claims and itemized bills) to verify payment and as needed for other public health purposes, including reporting to applicable vaccine registries.
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):

Clear
Printed Name
Relationship to Patient (if other than recipient)
Date Signed

MonthDayYear
Date
Should be Empty: