VaxOn Vaccine Consent Form

Vaccine consent form

Clinic Location:

875 Walnut St Suite 275-17, Cary, NC 27511

Appointment & Vaccine Selection
Appointment*
Which vaccine would you like to get?*

Flu Vaccine (4+)Moderna Bi-Valent Booster (12+)Pfizer Bi-Valent Booster (12+)Janssen/J&J (First Dose Only)Pediatric Pfizer Bi-Valent Booster (5-11)Pediatric Moderna Bi-Valent Booster (6-12)
Has it been 2 Months since your last primary or booster vaccine?*

YesNo

Patient Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Gender*
Race*
Ethnicity*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
I authorize VaxOn to text me or leave a detailed message regarding my visit today on the voicemail of the telephone number I have provided.*

YesNo

Please answer all the following Questions:*

	Yes	No
COVID-19 Screening Questions: 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 a known exposure with anyone who tested positive for COVID-19?
3- Have you had a 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?
Questionnaire for Immunization: 4- Do you feel sick today?
5- Do you have an allergy to medications, foods, or any vaccines (eggs, gelatin, thimerosal, neomycin, gentamicin, latex, aluminum, preservatives, baker's yeast, etc.)? ...................................
6- Have you received any vaccinations in the past 14 days?
7- Have you received COVID-19 monoclonal antibodies or convalescent plasma in the last 90 days?
8- Have you ever had a serious reaction or fainted after receiving any vaccination?
9- Have you ever had a seizure, brain disorder, or Guillain-Barre Syndrome?
10- Do you have any chronic health condition such as Cancer, Chronic Kidney Disease, Immunocompromised, Chronic Lung Disease, Obesity, Sickle Cell Disease, Diabetes, Heart Disease, Other? .................................................
For women:11- Are you pregnant or are you planning on becoming pregnant during the next month?

Primary Health Insurance Information
Do you have health insurance, Medicare, Medicaid or any commercial or government-funded health benefit plan?*

YesNo
Select insurance company, or Medicare or Medicaid plan*
Member number / ID number*
Group number (Optional)
Please upload your insurance Card*

Provide an image of your insurance card to help avoid errors in billing your insurance company.
Cancelof
Please provide a valid driver’s license/state ID number, which is used for the HHS Uninsured Program administration. You may continue to book an appointment if you do not have or prefer not to provide this information.
Driver’s license / state ID number*
State*
Please upload your Driver's License or state ID Card*

Cancelof

Vaccine consent form