COVID Vaccine Consent Form

Vaccine Consent Form

* Please fill out the required details below
Section I. Personal Information
Patient's Full Name:*

First NameMlLast Name
Date of Birth:*

MonthDayYear
Age:*
Phone Number:*
Email*
example@example.com
Not Used - do not delete.
Sex at Birth:*

MaleFemale
Ethnicity:

Hispanic or LatinoNon Hispanic/LatinoUnknownPrefer not to answer
Race:

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

Street Address Line 2
Primary Care Doctor:
Doctor City/State:
Which vaccine would you like to get at your appointment? You may get your COVID-19 and Flu vaccines on the same appointment. COVID VACCINE IS TEMPORALY UNAVAILABLE.*

Flu Vaccine (9-64 year old)Flu Vaccine (65+)Shingles Vaccine
Are you one of the following?

Essential WorkerFirst ResponderHealthcare WorkerPerson age 65+Person with chronic conditionResident of a care facility or other group settingNo, I am not any of the above
Please specify chronic condition:
https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html?utm_medium=email&utm_source=govdelivery
What dose of COVID-19 vaccine will this be?*

First DoseSecond DoseThird Dose / Booster Dose
When did you receive your last dose of covid shot?

MonthDayYear
Date
Section II. Questionnaire for Immunization

Please select the correct option below:

	Yes	No	Don't know or N/A
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 ever had a serious reaction or fainted after receiving any vaccination?
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?
Have you had an allergic reaction to Polyethylene glycol (peg) or Polysorbate?

Please specify the allergy from Q2:
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.**
Please pick a day and time for your 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 Person to Receive Vaccine & EUA/VIS (or Signature of Parent/Guardian if Patient is < 18 yo)

Clear
I have received a copy of the notice of Privacy Practices. I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.
Signature of Acknowledgment of Notice of Privacy Practices:

Clear
Please take or upload pictures of front & back of pharmacy benefits insurance card and your Medicare B card. If you do not have a Medicare B card than just your Rx card.

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.
Medicare Part B Number:
Please enter your Medicare Part B number even if you have Medicare Advantage or other insurance.
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 planI will pay out-of-pocket for all none COVID-19 vaccinesOther
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 NumberDrivers License or State ID number and the state of issuance
Date

MonthDayYear
Time

:HourMinutesAM/PM Option
Social Security Number
Drivers License Number or State ID number and state of issuance
Type in the ID then space and the state that issued you the ID.
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.
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