COVID-19 Vaccine Consent Form
We are now administering all COVID-19 vaccines Pfizer, Moderna, Novavax and Pediatric vaccines! (1st, 2nd and booster doses) Timings are MONDAY-FRIDAY: 9:45am-6:30pm and SATURDAY: 9:45am-2:45pm. Walk-ins are welcome!
Select an appointment time
Vaccine Recipient Name
Date of Birth
Vaccine Recipient Age
Vaccine Recipient Address
Vaccine Recipient Phone Number
Gender at birth
Black or African American
Hispanic or Latino
Not Hispanic or Latino
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?
5. Have you received any vaccines 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. Have you had a previous dose of the COVID-19 vaccine?
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
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet (the Janssen Fact Sheet is available after clicking submit), 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 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):
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.
If you are uninsured, please include your Drivers License Number, SSN, or State ID Number.
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
Which dose are you coming to receive?
Ped Moderna 3yrs-5yrs
Moderna Bivalent Booster 18+
Ped Pfizer 5yrs-11yrs
Ped Pfizer 3yrs-4yrs
Pfizer Bivalent Booster 12+
By signing this form, I attest that all information I have provided on this form is true and accurate, thereby qualifying me to receive a COVID-19 vaccine booster dose
Please Upload Supporting Uninsured Document
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First and Last Name
First and Last Name
Do you qualify to receive the COVID-19 Vaccine as per NJ State Mandate and Guidance for Phase 1a and Phase 1b vaccination?
No (Fill out the form and join our waitlist/standby) We will call contact you if available.
Submit Consent Form (required)
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