• Pre-Visit Checklist & Consent for COVID-19 Vaccine

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  • 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 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.)

  • 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.

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