Moderna COVID-19 Vaccine Appointment Scheduling and Consent Form

COVID-19 Vaccine Consent Form
Select an appointment time. Appointments will be held at Brehme Drug, 220 East Main Street, Manchester IA 52057. *
Vaccine Recipient Name *

First Name Middle Name Last Name
Vaccine Recipient Physical Address *

Street Address

Street Address Line 2

City State Initials

Postal / Zip Code
Email
example@example.com
Date of Birth *

Month Day Year
Gender at birth *
Race *
Ethnicity *
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 *

COVID-19 Vaccine Screen Questions *

	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 a component 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 received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19 in the previous 90 days? [note: monoclonal antibodies does not include antibiotics that you would be prescribed and filled at a pharmacy]
8. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
9. Do you have a bleeding disorder or are you taking a blood thinner?
10. Are you pregnant or breastfeeding?

COVID-19 Vaccine Manufacturer received for primary series (do not complete if you selected "no" to #2 above.)
Required if you selected "Yes" to #2
COVID-19 Vaccine Manufacturer received for booster dose(s), if different than primary series.
Required if you selected "Yes" to #2
Date(s) of previous COVID-19 vaccine(s)

Please provide dates of previous COVID-19 vaccination(s).
1st Dose:

Month Day Year
Required if you selected "Yes" to #2
2nd Dose:

Month Day Year
Date
3rd Dose:

Month Day Year
Date
4th Dose:

Month Day Year
Date

Consent (check each box below after reading and prior to signing the 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 (the Moderna Fact Sheet is available after clicking submit), a copy of which I was provided with this Consent Form. 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 Form.
I understand that at this time, the Moderna COVID-19 vaccine requires 2 doses given 28 days apart. If this is my second dose or booster 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 vaccination at no cost to me.

The vaccine is available to anyone no matter if insured or uninsured. Please check only one of the following. *

	Check one
If INSURED, check this box attesting to bringing in your prescription and medical insurance cards for your vaccine appointment. By selecting this, you are also authorizing the pharmacy to bill your insurance on your behalf for the immunization – understanding you will not incur any costs.
If UNINSURED, you must check this box to attest that the 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 benefit plan.

For uninsured patients, please select at least one of the following that you will bring with you to your appointment.

Social Security Number State identification number and state of issuance Driver's license number and state of issuance
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
Date of appointment selected above:

Month Day Year
Date
Time of appointment selected above:

Hour Minutes

AM/PM Option
Take photo of your Medicare A/B Card or prescription insurance card (if you do not have Medicare).
Should be Empty:

COVID-19 Vaccine Consent Form