Vaccine (Flu/COVID-19) Intake/Consent Form

Vaccine Recipient Information
Vaccine Recipient Name *

First Name Middle Name Last Name
Date of Birth *

Month Day Year
Current Date

Month Day Year
Date
Age
Parent/Guardian Information (must accompany minor at vaccination) *

Full Name Relationship
Vaccine Recipient Physical Address *

Street Address

Street Address Line 2

City State Initials

Postal / Zip Code
Gender at birth *
Race *
Ethnicity *
Vaccine Recipient Phone Number *
Mother's Maiden Name *
Required for proper vaccine documentation
Emergency Contact Name *
Relationship to Emergency Contact *
Phone Number of Emergency Contact *

Insurance
Select your insurance coverage. *

Social Security Number *
Medicare Beneficiary Identifier
Can be found on Medicare issued red, white, and blue card.
Prescription Billing Information

Using your prescription insurance card, complete the fields below or upload a photo of your card using the file upload.
BIN
PCN
Group
ID
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Cancel of

	Required
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 administration – understanding you will not incur any costs.

	Required
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.

Consent

COVID-19 Vaccine 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 (Click here for the Pfizer Fact Sheet, here for the Moderna Fact Sheet, or here for the Janssen Fact Sheet), 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 Pfizer and Moderna COVID-19 vaccine requires 2 doses given 21-28 days apart depending on the manufacturer. If this is my second 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.

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
Should be Empty:

	No	Yes
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, which is found in some vaccines, film coated tablets, and intravenous steroids?
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 something other than a component of COVID-19 vaccine, polysorbate, or any vaccine or injectable medication? (This would include food, pet, environment, or oral medication allergies)
5. Do you have a history of myocarditis or pericarditis?
6. Have you had a severe allergic reaction to something other than a vaccine or injectable therapy such as food, pet, venom, environmental or oral medication allergies?
7. Have you had COVID-19 and been treated with monoclonal antibodies or convalescent serum?
8. Have you been diagnosed with Multisystem Inflammatory Syndrome (MIS-C or MIS-A) after a COVID-19 infection?
9. Do you have a weakened immune system (i.e., HIV infection, cancer) or take immunosuppressive drugs or therapies?
10. Do you have a bleeding disorder?
11. Do you take a blood thinner?
12. Do you have a history or heparin-induced thrombocytopenia (HIT)?
13. Are you currently pregnant or breastfeeding?
14. Have you received dermal fillers?
15. Do you have a history of Guillain-Bar ré Syndrome (GBS)?

	No	Yes
1. Are you feeling sick today?
2. Do you have allergies to medications, food, eggs, yeast, a vaccine component, or latex?
3. Have you ever had a serious reaction after receiving a vaccination?
4. Has any physician or other healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a medical setting?
5. Do you have a long-term health problem such as heart disease, lung disease, liver disease, asthma, kidney disease, metabolic disease (e.g. diabetes), anemia or other blood disorder?
6. Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem? Have you been diagnosed with rheumatoid arthritis, ankylosing spondylitis, Crohn's disease, herpes, or cold sores?
7. In the past 3 months, have you taken medications that weaken your immune system such as cortisone, prednisone, other steroids, or anticancer drugs, or have you had radiation treatments?
8. Have you had a seizure or a brain or other nervous system problem or Guillain Barre?
9. During the past year, have you received a transfusion of blood products, or been given immune (gamma) globulin or antiviral drug (including acyclovir, famciclovir, valacyclovir)?
10. For women: Are you pregnant or is there a chance that you could become pregnant during the next month?
11. Have you received any vaccinations or TB skin tests in the past 4 weeks?
12. Do you have a history of fainting, particularly with vaccines?

Vaccine

Vaccine Recipient Information

COVID-19 Vaccine Screening Questions

General Vaccine Screening Questions

Insurance

Prescription Billing Information

Consent