COVID-19 Vaccine Consent Form
First, second and booster doses are available for all three vaccine types, Moderna, Pfizer and Johnson & Johnson. Pfizer is available for 5 years and older. Moderna and Johnson & Johnson are indicated for 18 years and older. Vaccine recipient must be 18 years old to receive the Moderna or Johnson and Johnson booster or 12 years or older to receive a Pfizer booster. As of 10/20/21 the CDC/FDA allow "Mix and Match" for booster doses. The booster dose can be of different manufacturer than previous dose(s). If you have any questions, you can reach the pharmacy at 281.351.5454 or by email at email@example.com.
Vaccine Recipient's Date of Birth:
Pfizer available for 5 years and older. Moderna and J&J plus all boosters must be 18 years or older.
Vaccine Recipient Name
Parent or Guardian's name (if vaccine recipient is less than 18 years old)
Which vaccine and dose are you registering for?
Moderna booster dose, 18+, (6 months after 2nd dose)
Moderna 2nd dose, 18+, (28 days after 1st dose)
Moderna 1st dose, 18+
Moderna additional 3rd dose for immunocompromised (uncommon)
Pfizer booster dose, 12+, (5 months after 2nd dose)
Pfizer 2nd dose, 12+ (21 days after 1st dose)
Pfizer 1st dose, 12+
Pfizer additional 3rd dose for immunocompromised (uncommon)
Johnson & Johnson booster dose, 18+, (2 months after initial dose)
Johnson & Johnson initial dose, 18+
Pfizer is available for 5 years and older. Moderna and Johnson & Johnson are indicated for 18 years and older. Vaccine recipient must be 18 years old to receive a booster of any type. As of 10/20/21 the CDC/FDA allow "Mix and Match" for booster doses. The booster dose can be of different manufacturer than previous dose(s).
Which dose are you registering for?
Pfizer 1st dose
Pfizer 2nd dose
Vaccine Recipient Physical Address
Street Address Line 2
District of Columbia
County of residence:
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
Vaccine Recipient e-mail address
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
Which vaccine and dose have you received most recently?
Moderna 1st dose
Moderna 2nd dose
Moderna additional dose for immunocompromised (uncommon)
Pfizer 1st dose
Pfizer 2nd dose
Pfizer additional dose for immunocompromised (uncommon)
Johnson & Johnson Initial dose
None of the above - This is my 1st dose
Select the date of most recent dose selected in previous question
What type of insurance do you have?
Commercial insurance (other than Medicare)
Please enter your Social Security number (required for Medicare)
Please enter your Social Security number - This will assist us if we have to search for insurance coverage
Please enter the following information from your PRESCRIPTION insurance card
BIN (6 digits)
ID or Member ID
Group or RxGroup
Please type your name exactly as it appears on your red, white and blue Medicare card.
Please type the number exactly as it appears on your red, white and blue Medicare card.
Please take a photo of your insurance card.
Please take a photo of your red white and blue Medicare card.
COVID-19 Vaccine Screen Questions
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
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 another vaccine (other than COVID-19 vaccine) or an injectable medication?
5. 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.
6. Have you received any vaccine in the last 14 days?
7. Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19?
8. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?
[note: monoclonal antibodies does not include antibiotics that you would be prescribed and filled at a pharmacy]
9. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
10. Do you have a bleeding disorder or are you taking a blood thinner?
11. Are you pregnant or breastfeeding?
12. Do you have dermal fillers?
13. Do you have a history of myocarditis or pericarditis?
14. Do you have a history of Gullian Barre Syndrome (GBS)?
15. Have you been diagnosed with Multisystem Inflammatory Syndrome after a COVID19 Infection?
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. 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, some COVID-19 vaccines require 2 doses given 21-28 days apart dependent on the manufacturer. If this is my first dose of the COVID-19 vaccine and a second dose is required (Pfizer and Moderna only), I intend to receive a second dose of the same vaccine in accordance with the timeframe specified in the fact sheet to complete the series.
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.
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.
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 provide social security number, driver's license or ID number and state of issuance
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is less than 18 years old):
Submit Consent Form (required)
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