UNC Charlotte 1/7 COVID/Flu Shot Form

UNC Charlotte COVID-19 Consent Form: South Village

Please read below carefully and ask for help if you need. This is a vaccination form for UNC Charlotte Students/Employees.
The COVID-19 vaccine will reduce the risk of becoming ill from the new type of coronavirus disease as known as COVID-19.

Please be aware that the vaccine is not 100% effective. It can take a few weeks for your body to build up protection from the vaccine. There is always a chance to become infected by coronavirus even with the vaccine; however, the vaccine lessens the severity of any infection. Two doses will reduce the chance of being seriously ill and reduce the risk of death due to coronavirus.

This vaccine produces a robust immune response. This is why it's so effective, but also why some people experience side effects following vaccination.

The most common side effects are:

Fever
Pain at the injection site
Redness and hardness of the skin at the injection site
Headache
Muscle aches or pain
Joint aches or pain
Fatigue (tiredness)
Nausea/vomiting
Chills
Typically, these side effects will be mild or moderate, and resolve within 12-48 hours. If you experience severe or long lasting symptoms, please remain calm and contact your doctor.

You should visit https://www.cdc.gov/vaccines/covid-19/eua/index.html and review the Fact Sheet for Recipients and Caregivers. If you have any questions or concerns after doing so, please consult your healthcare provider.
Personal Information
What Vaccines are you getting today?*

Pfizer Dose 1Pfizer Dose 2Pfizer Booster 1Pfizer Booster 2
Are you part of UNC Charlotte?*

StudentStaffFamily of StudentFamily of StaffOther
UNC Charlotte 800 ID# (N/A if family)*
Name*

First NameLast Name
Email*

Confirmation Emailexample@example.com
Date of Birth*

MonthDayYear
Date
Full Address*

Example: 123 Main St, Apt 6

Street Address Line 2

CityState

Zip Code
County*
Example: Mecklenburg, Iredell, Cabarrus, Gaston
Phone Number*
Please enter a valid phone number.
Gender*
Race/Ethnicity*

BlackAmerican IndianHispanicWhiteAsianOther
Medical History
Are you feeling sick today?*
When did you receive your last dose of COVID-19 vaccine?*

MonthDayYear
Date
Have you ever had an allergic reaction a vaccine or:*

Polyethylene glycolPolysorbateA previous dose of the COVID-19 vaccineN/AOther
Check all that apply to you

Am a female between ages 18 and 49 years oldAm a male between ages 12 and 29 years oldHave 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 after a COVID-19 infectionHave a bleeding disorderTake a blood thinnerHave a weakened immune system or take immunosuppressive drugs or therapiesHave a history of heparin-induced thrombocytopeniaAm currently pregnant or breastfeedingHave received dermal fillersHistory of Guillain-Barre Syndrome
Emergency Contact Information
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relation
Parent or Guardian Information

Filling this out and signing means you consent to your minor getting the vaccine
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relation*
Pharmacy Insurance Coverage

If none, enter N/A
Carrier Name*

AetnaAnthemBCBSCaremarkCignaExpress ScriptsHumanaMedicaidOptumRxTricareUnited HealthcareMedicare Part BNoneOther
Rx BIN
PCN (if available)
ID Number*
Your vaccine will be covered under standard Medicare Part-B. Please provide your ID# from your red, white and blue medicare card.*
Group Number*
Relation to Cardholder*
Appointment (If you cannot select a time, we are filled for this week, look for another clinic soon!)
By signing this form,

I hereby accept that I have read and understood the acknowledgment letter provided above.

I declare that the information I have provided above is correct.

I am giving my consent to get the COVID-19 vaccination and/or the Flu shot of my own will.
Signature*

Clear
Parent or Guardian's Signature*

Clear
Should be Empty:

UNC Charlotte COVID-19 Consent Form: South Village

Personal Information

Medical History

Emergency Contact Information

Parent or Guardian Information

Pharmacy Insurance Coverage