COVID-19 Immunization Screening and Consent Form

Name *

First Name Last Name

Facility Name *

Sex *

Date of Birth *

Date

Email *

example@example.com

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number *

Please enter a valid phone number.

Medicare *

Upload a photo of Insurance Card

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Social Security Number *

Are you feeling sick today? *

Yes No

In the last 10 days, have you had a COVID-19 test because you had symptoms and are still awaiting your test results or been told by a health care provider or health department to isolate or quarantine at home due to COVID-19 infection or exposure? *

Yes No

Have you been treated with antibody therapy or convalescent plasma for COVID-19 in the past 90 days? *

Yes No

If yes, when did you receive the last dose? Date:

Have you ever had an immediate allergic reaction (e.g. hives, facial swelling, difficulty breathing, anaphylaxis) to any vaccine, injection, or shot or to any component of the COVID-19 vaccine, or a severe allergic reaction (anaphylaxis) to anything? *

Yes No

Are you pregnant or considering becoming pregnant? *

Yes No

Do you have a bleeding disorder, a history of blood clost or are you taking a blood thinner? *

Yes No

Do you have a history of myocarditis (inflammation of the heart muscle) or pericarditis (inflammation of the lining around the heart? *

Yes No

Do you have cancer, leukemia, HIV/AIDS or any other condition that weakens the immune system? *

Yes No

Have you received 2 doses of the Pfizer or Moderna vaccine, the second dose being at least 6 months ago? *

Yes No

Have you received a previous dose of Janssen COVID-19 vaccine? (If yes, it is recommended you receive the Moderna or Pfizer vaccine.) *

Yes No

If Yes, Date Received:

This is my *

1st Dose 2nd Dose 3rd Dose 4th Dose

If this will be your 2nd, 3rd, or 4th dose, which vaccine have you previously received? *

J&J Moderna Pfizer Not applicable

I request that the COVID-19 vaccination be given to me (or the person named above for whom I am authorized to make this request and provide surrogate consent.) I understand there will be no cost to me for this vaccine. I understand that any monies or benefits for administering the vaccine will be assigned and transferred to the vaccinating provider, including benefits/monies from my health plan, Medicare or other third parties who are financially responsible for my medical care. I authorize release of all information needed (including but not limited to medical records, copies of claims and itemized bills) to verify payment and as needed for other public health purposes, including reporting to applicable vaccine registries. *

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COVID-19 Consent Form