COVID Vaccine Consent Form

Children's (*5-11yr old) Covid Primary & Bivalent Vaccine Consent Form

* Please complete required details below. If you have questions, please call us at (803) 649-1776 or (803) 648-1776.
Section I. Personal Information
Patient's Full Name:*

First NameMlLast Name
Date of Birth:*

MonthDayYear
Age:*
Phone Number:*
Social Security Number *
Please enter your Social Security Number. This provides us the ability to better locate applicable insurance information and if uninsured, allows us to upload information to the HRSA fund for administration reimbursement.
Mother's Maiden Name
Parent/Guardian Email:*
Gender:*

MaleFemale
Ethnicity:*

Hispanic or LatinoNon Hispanic/LatinoUnknownPrefer not to answer
Race:*

African AmericanAmerican IndianAsianCaucasianNative Hawaiian/Other Pacific IslanderPrefer not to answer
Address:*

Street Address Line 2
Pediatrician*
Doctor City/State:*
What Pfizer (5-11yr old) dose of COVID-19 vaccine will this be?*

Bivalent Booster Pfizer 5-11 yr oldFirst Dose Pfizer 5-11 yr old (10mcg dose)Second Dose Pfizer 5-11 yr old (10mcg dose)Bivalent Moderna Booster (6 yr old - 11 yr old)
If this is your Booster dose, when did you receive your most recent dose?*

MonthDayYear
Date
Section II. Questionnaire for Immunization

Please select the correct option below:*

	Yes	No	Don't know or N/A
Are you feeling sick today?
Have you ever received a dose of Covid-19 Vaccine?
Have you had a previous allergic reaction to a component of the Covid-19 vaccine, including polyethylene glycol, which is found in some medication, such as laxatives and preparations for colonoscopy procedures?
Have you had an allergic reaction to another vaccine or an injectable medication (*severe reaction requiring medical treatment and/or epinephrine)
Have you ever had a severe allergic reaction (i.e. anaphylaxis) to something other than a component of the vaccine?
Have you ever had a positive test for Covid-19 or has a health care provider ever told you that you had Covid-19?
Have you received passive antibody treatment (monoclonal antibodies or convalescent serum) as treatment for Covid-19?
Do you have a weekend immune system caused by something such as HIV infection, cancer, or do you take immunosuppressive drugs or therapies?
Do you have a bleeding disorder or are you taking a blood thinner?
Do you have a history of Multisystem Inflammatory Syndrome (MIS-C)

Please specify the allergy from Q3, Q4, or Q5:
Section III. Appointment Scheduler
**Vaccine supply is limited. Please keep your appointment or call if you need to cancel or change it. Additionally, due to vaccine requirements; we may call you to see if you can come earlier, later or to a nearby location. If you miss an appointment, no doses will be held to guarantee your dose.**
**NEWBERRY STREET -- Please pick a day and time for your 5-11 yr old's vaccination:
**PRICE AVENUE (SOUTH AIKEN) -- Please pick a day and time for your 5-11 yr old's vaccination:
Section IV. Signatures I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) (insert link to EUA), a copy of which I was provided with this Consent and Release. 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 Parent/Guardian for Minor Patient)*

Clear
Signature of Acknowledgment of Notice of Privacy Practices:*

Clear
Please take or upload pictures of front & back of insurance card for billing purposes

Browse Files

Cancelof
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
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.
Should be Empty:

Children's (*5-11yr old) Covid Primary & Bivalent Vaccine Consent Form