COVID Vaccine Consent Form

COVID Vaccine Consent Form
PATIENT / RESIDENT INFORMATION:
NAME*

FIRST NAMELAST NAME
ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
COUNTY*
DATE OF BIRTH*

MonthDayYear
Date
GENDER*
ETHNICITY*

Hispanic or LatinoNot Hispanic or Latino
RACE*

WhiteBlackAsianAmerican Indian/Alaska NativeNative Hawaiian or Other Pacific IslanderOtherUnknown

QUESTIONS

COVID-19 SCREENING QUESTIONS*

	YES	NO	I DON’T KNOW
1. In the past two weeks, have you tested positive for COVID-19 or are you currently being monitored for COVID-19?
2. In the past two weeks, have you had contact with anyone who tested positive for COVID-19?
3. Have you had new onset of fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, nausea, vomiting, or diarrhea?

IMMUNIZATION SCREENING QUESTIONS*

	YES	NO	I DON’T KNOW
Are you sick today? For example: cold, fever, acute illness?
Do you any allergies/reactions to any medications, vaccines, food or latex? For example: eggs, gelatin, neomycin, thimerosal, etc.
Have you ever had a serious reaction after receiving a vaccination? Have you ever fainted, particularly with vaccines? Have you 3. ever been cautioned or warned about receiving certain vaccines or receiving vaccines outside of a medical setting by a doctor or other healthcare professional?
Do you take anticoagulation medication? For example: Coumadin/warfarin or other blood thinner?
Have you had a seizure or a brain or other nervous system problem or Gillian Barre?
Do you have a long-term health problem such as heart disease, lung disease, liver disease, asthma, kidney disease, metabolic 6. disease (e.g. Diabetes), anemia, or other blood disorder?
Do you have cancer, leukemia, rheumatoid arthritis, HIV/AIDS, ankylosing spondylitis, Crohn’s disease or any other immune system 7. problem?
Do you have a weakened immune system or in past 3 months, taken medication that weaken it such as cortisone, prednisone, 8. other steroids, anticancer drugs, or radiation treatments?
During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an 9. antiviral drug?
For WOMEN, are you pregnant or is there a chance you could become pregnant during the next month?
Have you received any vaccination or TB skin test in the past 4 weeks?

I have read the Vaccine Information Sheet or fact sheet about the corresponding vaccine(s) I am receiving. I have had a chance to ask questions to my satisfaction. I understand the benefits and risks of the vaccine and request that the vaccine be given to me or to the person named above for whom I am authorized to make the request. I authorize the release of any medical information or other information necessary to process an insurance claim. I understand that if applicable, Specialty RX (Citywide RX LLC) will submit my claim to insurances they contract with. I certify that all Medicare information given to Specialty RX (Citywide RX LLC) Pharmacy is true. Specialty Rx (Citywide RX LLC) has made their “Notice of Privacy Practices” available to me. I authorized the release of any medical or other information with respect to this vaccine to my healthcare providers, Medicare, Medicaid, the HRSA COVID-19 program for the uninsured, or other third party payer as needed and request payment of authorized benefits to be made on my behalf to Specialty RX (Citywide RX LLC) Pharmacy. I acknowledge that my vaccination record may be shared with federal or state or city agencies for registry reporting. I agree to stay in the general area for at least fifteen (15) minutes after receiving my vaccination for any potential adverse reactions. I understand if I experience side effects that I should contact a doctor, pharmacy, call 911 if an emergency.
Signature*

Clear
Date*

MonthDayYear
Date
Are you signing on behalf of the resident?*

YesNo
If signing on behalf of the patient, you affirm that you are authorized to provide the required consents on behalf of the patient
NAME OF AUTHORIZED PERSON*
First and Last Name
RELATIONSHIP*
Phone Number*
Please enter a valid phone number.
Should be Empty:

COVID Vaccine Consent Form

PATIENT / RESIDENT INFORMATION:

VACCINE INFORMATION

QUESTIONS