COVID Vaccine Consent (FILL OUT ON SHOT DAY)

COVID-19 Immunization Questionnaire
Please read the information sheet (below) from the CDC for the Pfizer COVID-19 vaccine, then complete the following questionnaire and consent form. Please ask all questions you may have.

Please Note: If you are receiving your first dose today, please contact us in 3 weeks to schedule your booster dose. If you are receiving your second dose, please contact us in 8 weeks to schedule your final dose. Thanks very much!

***Children receiving vaccines should remain in the vehicle with their seat belts fastened***
FACT SHEET FOR RECIPIENTS AND CAREGIVERS ABOUT THE PFIZER- BIONTECH COVID-19 VACCINE TO PREVENT CORONAVIRUS DISEASE 2019 (COVID-19) FOR USE IN INDIVIDUALS 6 MONTHS THROUGH 4 YEARS OF AGE.
Is the patient sick today? *

Yes No Don't know
Has the patient ever received a dose of COVID-19 vaccine? *

Yes No
If the above is "yes,' which vaccine product did you receive?

Pfizer Moderna Johnson & Johnson
Has the patient ever had an allergic reaction to a previous COVID-19 vaccine or any component of a COVID-19 vaccine, including polyethylene glycol (PEG) or polysorbate? *

Yes No
Has the patient ever had a severe allergic reaction (anaphylaxis) to medications, food, latex or any vaccine? *

Yes No
If yes to the above, please list:
Does the patient have cancer, leukemia, AIDS, or any other immune system problem? *

Yes No
Has the patient had a seizure, brain, or other nervous system problem? *

Yes No
Consent for Immunization
Patient Name *

First Name Last Name
Patient Date of Birth *

Month Day Year
I have been given a copy and have read, or have had explained to me, the information provided by the Centers for Disease Control (CDC) for the COVID-19 vaccine I/my child am to receive today.

I have had a chance to ask questions and they have been addressed to me satisfaction.

I understand the benefits and risks of the COVID-19 vaccine to be given.

I give my consent for the COVID-19 vaccine to be given to me/my child at this time.
Parent/Guardian/Patient (if over 18 yrs of age): *

First Name Last Name
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

COVID-19 Immunization Questionnaire

Consent for Immunization