COVID-19 Vaccine Consent Form
In order to receive the vaccine, you must be in the most appropriate phase of the vaccine rollout. Visit this link (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations.html) for more information at the federal level. States may have a different approach.
Please select the type of vaccine you would like to receive:
Select an appointment time for the COVID-19 Vaccine (Parent/legal guardian should provide consent if less than 18 years of age)
Vaccine Recipient Name
Vaccine Recipient Physical Address
Date of Birth
Gender at birth
American Indian or Alaska Native
Black or African American
Native Hawaiian or Other Pacific Islander
Hispanic or Latino
Not Hispanic or Latino
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
1. Are you feeling sick today?
2. In the last 10 days, have you had a COVID-19 Test because you had symptoms and are still awaiting your test results or been told by a healthcare provider or health department to isolate or quarantine at home due to COVID-19 infection, exposure, or travel?
3. Have you been treated with antibody therapy or convalescent plasma for COVID-19 in the past 90 days (3 months)?
4. 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
Have you received any vaccine in the last 14 days
6. Are you pregnant or considering becoming pregnant or breastfeeding?
7. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
8. Do you take any medications that affect your immune system, such as cortisone, prednisone, or other steroids, anticancer drugs, or have you had any radiation treatments?
9. Do you have a bleeding disorder or are you taking a blood thinner?
10. Are you 18 years old or older, and have you received 2 doses of the Pfizer vaccine, the second dose being at least 6 months ago?
Have you received 2 doses of the Moderna vaccine, the second dose being at least 6 months ago?
12. Have you received a previous dose of the Janssen vaccine, at least 2 months ago?
13. If you had a previous dose of Janssen (Johnson & Johnson), did you develop thrombosis with thrombocytopenia syndrome (TTS)?
14. Have you received a previous dose of a non-FDA authorized or approved COVID-19 vaccine authorized by the WHO1 but not by the FDA (AstraZeneca – VAXZEVRIA, Sinovac –CORONAVAC, Serum Institute of India – COVISHIELD, Sinopharm/BIBP, COVAXIN)?
Which arm would you like to get the injection on
Consent (check each box below after reading and prior to signing the form)
Check each box
Emergency Use Authorization
the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet, a copy of which I was provided. Emergency Use Authorization. The FDA has made the COVID-19 vaccine available under an emergency use authorization (EUA). The EUA is used when circumstances exist to justify the emergency use of drugs and biological products during an emergency, such as the COVID-19 pandemic. This vaccine has not undergone the same type of review as an FDA-approved or cleared product. However, the FDA’s decision to make the vaccine available is based on the totality of scientific evidence available, showing that known and potential benefits of the vaccine outweigh the known and potential risks. Please note: FDA approved the Pfizer-BioNTech COVID-19 vaccine as a two-dose series in individuals 16 years of age and older. The vaccine continues to be available under an EUA for certain populations, including for those individuals 5 through 15 years of age and for the administration of a third dose in the populations set forth in the consent section below.
I have read,
or had explained to me, the information sheet about the COVID-19 vaccination. I understand that if my vaccine requires two doses, I
will need to be administered (given) two doses to be considered fully vaccinated. Further, I understand that a booster dose of COVID-19 vaccine
may be recommended at least 2 months following the first dose of Janssen vaccine or at least 6 months following the second dose of PfizerBioNTech or Moderna COVID-19 vaccine if I am a member of a certain population (e.g., 65 years or older, 18 years old or older and a resident of a long term care facility, 50-64 years with an underlying medical condition, 18-49 years old with an underlying medical condition based on individual benefits and risks, 12-64 years old and at an increased risk for COVID-19 exposure and transmission because of working or living in a high-risk setting and based on individual benefits and risks) to increase my protection. I have had a chance to ask questions which were answered to my satisfaction (and ensured the person named above for whom I am authorized to provide surrogate consent was also given a chance to ask questions). I understand the benefits and risks of the vaccination as described.
that the COVID-19 vaccination be given to me (or the person named above for whom I am authorized to make this request and provide
surrogate consent). I authorize release of all information needed (including but not limited to medical records, copies of claims and itemized bills) to verify payment and as needed for other public health purposes, including reporting to applicable vaccine registries.
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.
that at this time, the COVID-19 vaccine requires 2 doses given 21-28 days apart (unless single dose Johnson & Johnson) depending on the manufacturer. If this is my second dose, I will bring my vaccine card with me to be completed.
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.
there will be no cost to me for this vaccine. I understand that any monies or benefits for administering the
vaccine will be assigned and transferred to the vaccinating provider (Super Health Pharmacy), including benefits/monies from my health plan, Medicare or other third
parties who are financially responsible for my medical care.
The vaccine is available to anyone no matter if insured or uninsured. Please check only one of the following.
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.
Please Upload Insurance Card
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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
Please Upload Supporting Uninsured Document
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Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):
First and Last Name
First and Last Name
Should be Empty: