Form

Patient Name*

First NameLast Name

Patient Date of Birth*

Date

Is this the patient's first or second dose of the COVID 19 vaccination?*

First DoseSecond Dose

The following questions will help us determine if there is any reason you should not get the COVID-19 vaccine at your upcoming appointment. If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions may be asked.

Has the patient ever received a dose of COVID-19 vaccine?

YesNoI don't know

Has the patient ever had an allergic reaction to any of the following choices below: (This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen© of that caused you to go to the hospital. It would also include an allergic reaction that caused hives, swelling or respiratory distress, including wheezing.)

1. A component of a COVID-19 vaccine, including either of the following: a. Polyethylene glycol (PEG), which is found in some medications, such as laxatives or preparations for colonoscopy procedures. b. Polysorbate, when is found in some vaccines, film coated tables, and intravenous steroids.*

YesNoI don't know

2. A previous dose of the COVID-19 Vaccine?*

YesNoI don't know

3. Has the patient ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?*

YesNoI don't know

Check all that apply to the patient*

Is currently in quarantine for a COVID-19 diagnosis or recent exposureHas a history of myocarditis or pericarditisHad a severe allergic reaction to something other than a vaccine or injectable therapy such as food, pet, venom, environmental or oral medication allergiesHad COVID-19 and was treated with monoclonal antibodies or convalescent serumDiagnosed with Multisystem Inflammatory Syndrome (MIS-C) after a COVID-19 infectionHas a bleeding disorder or takes a blood thinnerHas a weakened immune system (ie. HIV infection, cancer) or takes immunosuppressive drugs or therapiesHas a history of Guillian-Barre Syndrome (GBS)None of the above

Patient Insurance Information*

Patient has insurancePatient is uninsured/self pay

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 the United States Health Resources & Services Administration's COVID-19 Program for Uninsured Patients, please provide either (a) a valid Social Security number, (b) state identification number and state of issuance, OR (c) a driver's license number and the state of issuance.

If uninsured, please list SSN or identification number.

I have been provided with the Emergency Use Authorization Sheet(s) or patient fact sheet corresponding to the vaccine(s) that I am receiving. I have read the information provided about the vaccine I am to receive. I have had the chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of vaccination and I voluntarily assume full responsibility for any reactions that may result. I understand that I should remain in the vaccine administration area/parking lot for 15 minutes after the vaccination to be monitored for any potential adverse reactions (or 30 minutes if I am high risk). I understand if I experience side effects that I should call the physician on call or, call 911. I request that the vaccine be given to me or to the person named above for whom I am authorized to make this request. AUTHORIZATION TO REQUEST PAYMENT: I do hereby authorize Pediatric Center at Renaissance to release information and request payment. I certify that the information given by me in applying for payment under Medicare or Medicaid, or the HRSA COVID-19 Program for Uninsured Patients, is correct. I authorize release of all records to act on this request. I request that payment of authorized benefits be made on my behalf. DISCLOSURE OF RECORDS: I understand that Pediatric Center at Renaissance may be required to or may voluntarily disclose my health information to third party payors, my health insurance, other health practitioners, and/or state or federal registries, for purposes of treatment, payment or other health care operations (such as administration or quality assurance). I also understand that Pediatric Center at Renaissance will use and disclose my health information as set forth in the our Notice of Privacy Practices (copy is available online or by requesting a paper copy from the office) I understand that Pediatric Center at Renaissance provides immunization information to the Texas Immunization Registry, ImmTrac.

Signature of Parent, Guardian or Authorized Representative*

Clear

Name of Parent, Guardian or Authorized Representative*

First NameLast Name

Date*

Date

Pre-Visit Checklist & Consent for COVID-19 Vaccine