COVID-19 Immunization Screening and Consent Form

COVID-19 Consent Form
Name*

First Name Last Name
Are you a resident of a Long Term Care facility or an employee/staff member ?*

Yes, ResidentYes, Staff MemberNo
Facility Name *
Sex*
Date of Birth*

MonthDay Year
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.
Do you have Medicare?*

YesNo
Please enter your Medicare ID #*
Pharmacy Insurance Card Name *
We reserve the right to reject your vaccine if this section is filled out incompletely.
Pharmacy Insurance ID# *
We reserve the right to reject your vaccine if this section is filled out incompletely.
Insurance Bin # *
We reserve the right to reject your vaccine if this section is filled out incompletely.
Insurance PCN # *
We reserve the right to reject your vaccine if this section is filled out incompletely.
Insurance Group # *
We reserve the right to reject your vaccine if this section is filled out incompletely.
Upload a photo of Pharmacy Insurance Card

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Cancelof
Social Security Number*
Are you feeling sick today?*

YesNo
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?*

YesNo
Have you been treated with antibody therapy or convalescent plasma for COVID-19 in the past 90 days (3 months)? If yes, when did you receive the last dose? Date:*

YesNo
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?*

YesNo
This will be my*

1st Dose (Primary Series)2nd Dose (Primary Series)Booster Dose (Bivalent)
If you have previously received the COVID-19 vaccine, which COVID-19 vaccine have you previously received?*

ModernaPfizerNovavaxJ&JNot applicable
The FDA authorized bivalent formulations of the Moderna and Pfizer-BioNTech COVID-19 vaccines for use as a single booster dose at least two months after completing either your primary series or monovalent booster vaccination.

The Moderna COVID-19 Vaccine, Bivalent is authorized for use as single booster dose in individuals 18 years of age and older.

The Pfizer-BioNTech COVID-19 Vaccine, Bivalent is authorized for use as a single booster dose in individuals 12 years of age and older.

You are considered up to date with your COVID-19 vaccines immediately after getting your updated (bivalent) booster.

The vaccine will be administered in the upper arm, please wear loose-fitting clothing for easier access to this area.
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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