COVID-19 Vaccine Consent Form
Please complete the form below. This assessment is intended to be used as a screening tool prior to the administration of the COVID-19 vaccine. This is not a diagnostic tool for determining COVID-19. All patients with confirmed or suspected cases of COVID-19 should follow CDC and physician guidance and refrain from immunizations until directed by a medical professional. Additional questions within this document are included to provide further screening for the COVID-19 vaccine.
Vaccine Recipient Name
*
First Name
Middle Name
Last Name
Email
*
example@example.com
Vaccine Recipient Physical Address
*
Street Address
Street Address Line 2
City
State Initials
Postal / Zip Code
Date of Birth
*
/
Month
/
Day
Year
Gender at birth
*
Please Select
Male
Female
Race
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Ethnicity
*
Please Select
Hispanic or Latino
Not Hispanic or Latino
Unknown
Vaccine Recipient Phone Number
*
Mother's Maiden Name
*
Required for proper vaccine documentation
Primary Care Provider Name
Emergency Contact Name
*
Relationship to Emergency Contact
*
Phone Number of Emergency Contact
*
Select an appointment time
*
Type a question
Yes
No
1. Are you feeling sick today?
2. Have you ever received a dose of COVID-19 Vaccine?
3a. Have you ever had an allergic reaction to acomponent of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures?
3b. Have you ever had an allergic reaction to Polysorbate?
3c. Have you ever had an allergic reaction to a previous dose of COVID-19 Vaccine?
4. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?
5. 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
6. Have you received any vaccine in the last 14 days?
7. Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19?
8. 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]
9. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
10. Do you have a bleeding disorder or are you taking a blood thinner?
11. Are you pregnant or breastfeeding?
12. Do you have a history of or a risk factor for a blood clotting disorder?
13. Do you have Dermal Fillers
COVID-19 Vaccine Manufacturer for the first dose received (do not complete if you selected "no" to #2 above.)
*
Please Select
Moderna
Pfizer
Johnson & Johnson
Select Desired Vaccine Type
*
Please Select
Moderna
Johnson & Johnson
Please Upload a Picture of the Front of Your Insurance Card Here If you do not have insurance please upload a copy of your government issued ID
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of
Please Upload a Picture of the Back of Your Insurance Card Here If you do not have insurance please upload a copy of your government issued ID
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):
*
Clear
Date Signed
*
/
Month
/
Day
Year
Date
Submit Consent Form And Schedule Appointment
Should be Empty: