COVID-19 Consent Form
Name
*
First Name
Last Name
Facility Name
*
Sex
*
Please Select
Male
Female
Date of Birth
*
-
Month
-
Day
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.
Social Security Number
*
Medicare ID Number
*
(The vaccines are provided free of charge regardless of insurance coverage and you will not be billed)
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Are you feeling sick today?
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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?
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Yes
No
Have you been treated with antibody therapy or convalescent plasma for COVID-19 in the past 90 days?
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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?
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Yes
No
Are you pregnant or considering becoming pregnant?
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Yes
No
Do you have a bleeding disorder, a history of blood clost or are you taking a blood thinner?
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Yes
No
Do you have a history of myocarditis (inflammation of the heart muscle) or pericarditis (inflammation of the lining around the heart?
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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?
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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
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1st Dose
2nd Dose
3rd Dose
4th Dose
If this will be your 2nd, 3rd, or 4th dose, which vaccine have you previously received?
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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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