COVID VACCINE MODERNA/PFIZER

Section 1: Vaccine Recipient Information

Name: *

Date of Birth: *

Phone Number: *

Email Address:

Primary Healthcare Provider:

Address: *

Street Address (NO PO BOXES)

Street Address Line 2

City State

Zip Code

Gender *

Ethnicity: *

Race: *

What dose of the COVID-19 Vaccine will this be? *

First Dose Second Dose Third dose

What vaccine would you like to receive? *

Pfizer (12 years & older, 2 shots total, dosed 21 days apart) Moderna (18 years & older, 2 shots total, dosed 28 days apart)

What vaccine did you receive? *

Pfizer Moderna Other

When did you receive the 1st dose? *

Date

When did you receive the 2nd dose? *

Date

For third booster, please select one of the following options. *

Immunocompromised General population

For immunocompromised, please explain. If 3rd shot is for general population, 3rd vaccines MUST be after September 20th and MUST be at least 8 months from 2nd shot., Type in "YES" if your 3rd vaccine will be beyond 8 months from your 2nd dose. *

Section 2: COVID-19 Pre Vaccination Assessment:

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.

Please answer the following: *

	Yes	No	Don't know
1. Are you feeling sick today?
2. Have you ever had a severe allergic reaction (e.g. anaphylaxis) to something? For example, a reaction for which you were treated with epinephrine or EpiPen, or for which you had to go to the hospital?
3. In the last 90 days, have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as a treatment for COVID-19?
4. Have you received another vaccine in the last 14 days?
5. In the last 14 days, have you tested positive for COVID-19?
6. Do you have a weakened immune system caused by something, such as HIV infection or cancer, or do you take immunosuppressive drugs or therapies?
7. Do you have a bleeding disorder or are you taking a blood thinner?
8. Are you pregnant or breastfeeding?

Please pick an appointment slot for your vaccination *

Prescription insurance (type "1" if pharmacy already has):
ID #: * RX BIN: *
RX GROUP (GRP): * RX PCN: *

***MEDICARE PATIENTS:
***If medicare, please provide ID number (Red, White, Blue card):
MEDICARE NUMBER HERE

Section 3: Consent

I have read or have had explained to me the information provided in the Emergency Use Authorization for pfizer (HERE) or for moderna (HERE). I have had a chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of COVID-19 vaccine and ask that the vaccine be administered to me or the person named above for whom I am authorized to make this request.

Signature: *

Clear

COVID Vaccine Consent Form