COVID Vaccine Consent Form

If you have remaining questions, please call us at (336)-570-2273.

Section I. Personal Information

Patient's Full Name: *

First Name Ml Last Name

Date of Birth: *

Age: *

Phone Number: *

Medicare Part B Number:

Please enter your Medicare Part B number even if you have Medicare Advantage or other insurance.

Email:

Gender: *

Male Female

Ethnicity: *

Hispanic or Latino Non Hispanic/Latino Unknown Prefer not to answer

Race: *

African American American Indian Asian Caucasian Native Hawaiian/Other Pacific Islander Prefer not to answer

Address: *

Street Address Line 2

Primary Care Doctor: *

Doctor City/State: *

What dose of COVID-19 vaccine will this be? *

First Dose (Moderna) Second Dose (Moderna) Third Dose (Moderna) Fourth Dose (Moderna)

When did you receive your last dose? *

Date

Please select the correct option below: *

	Yes	No	Don't know or N/A
COVID-19 Screening Questions:In the past two weeks, have you tested positive for COVID-19 or are you currently being monitored for COVID-19?
In the past two weeks, have you had a known exposure with anyone who tested positive for COVID-19?
Have you had a new onset of fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, nausea, vomiting, or diarrhea?
Questionnaire for Immunization: Do you feel sick today?
Do you have an allergy to medications, foods, or any vaccines (eggs, gelatin, thimerosal, neomycin, gentamicin, latex, aluminum, preservatives, baker's yeast, etc.)?
Do you carry an EpiPen?
Have you been diagnosed with or suspected of having covid in the last 90 days?
If yes to the above question, did you receive medications, plasma or other treatment?
Have you ever had a serious reaction or fainted after receiving any vaccination?
Have you ever had a seizure, brain disorder, or Guillain-Barre Syndrome?
Have you received any other immunizations in the last 14 days?
For women: Are you pregnant or are you planning on becoming pregnant during the next month?

Section II. Appointment Scheduler

Please pick a day and time for your vaccination *

Section III. Signatures I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA), (Moderna or Janssen) a copy of which is linked above and will be provided at my appointment. 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 and Release.

Signature of Person to Receive Vaccine & EUA/VIS *

Clear

I authorize the pharmacy to bill my insurance on my behalf for the immunization and the information provided is true and accurate.

If uninsured, you must check the box below to attest that 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 health benefit plan

In order to have your vaccine administration fee paid for by the United States Health Resources & Services Administration's COVID-19 Program for uninsured patients, please select to provide one of the following: *

Social Security Number State identification number and state of issuance Driver's license number and state of issuance

Social Security Number

State identification number and state of issuance *

Driver's license number and state of issuance *

By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.