Moderna COVID-19 Vaccine Consent Form
In order to receive the vaccine or booster, you must be in the most appropriate phase of the vaccine rollout. Visit the cdc website (https://www.cdc.gov) for more information at the federal level. States may have a different approach. Immunization will be entered into MA Vaccine registry unless advised otherwise at time of vaccination.
Select an appointment time
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Email
example@example.com
Vaccine Recipient Name
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First Name
Middle Name
Last Name
Vaccine Recipient Physical Address
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Street Address
Street Address Line 2
City
State Initials
Postal / Zip Code
Date of Birth
*
/
Month
/
Day
Year
Gender at birth
*
Please Select
Male
Female
Race
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Ethnicity
*
Please Select
Hispanic or Latino
Not Hispanic or Latino
Unknown
Vaccine Recipient Phone Number
*
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
*
COVID-19 Vaccine Screen Questions
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Yes
No
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 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.
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?
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?
COVID-19 Vaccine Manufacturer for the last dose received (do not complete if you selected "no" to #2 above.)
Please Select
Moderna
Pfizer
Janssen (J&J)
Required if you selected "Yes" to #2
Date of last dose (do not complete if you selected "no" to #2 above.)
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Month
/
Day
Year
Required if you selected "Yes" to #2
Consent (check each box below after reading and prior to signing the form)
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Check each box
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.
The vaccine is available to anyone no matter if insured or uninsured. Please check only one of the following.
*
Check one
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
Signature of Person to Receive Vaccine (or Signature of Parent/Guardian if Patient is < 18 years old):
Clear
Date Signed
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Month
/
Day
Year
Date
Submit Consent Form (required)
Should be Empty: