COVID-19 Immunization Screening and Consent Form

2023–2024 Updated COVID-19 Vaccine Consent Form
Name*

First NameLast Name
Are you a resident of a long-term care facility, adult home, adult day healthcare facility, enriched housing program, etc. or an employee/staff member of a facility?*

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

MonthDayYear
Date
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
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

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

YesNo
Has the person to be vaccinated today previously been vaccinated with a COVID-19 vaccine?*

YesNo
If yes, which product was administered?

PfizerModernaJanssen (Johnson & Johnson)NovavaxOther
Has it been over 60 days since your received your last COVID-19 vaccine?*

YesNo
Which COVID-19 vaccine are you requesting today?*

Pfizer (COMIRNATY®)Moderna (SPIKEVAX®)
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
Do you have a history of myocarditis (inflammation of the heart muscle) or pericarditis (inflammation of the liningaround the heart)?

YesNo
Do you have a bleeding disorder, a history of blood clots or are you taking a blood thinner?

YesNo
Do you have a history of MIS-C or MIS-A (multisystem inflammatory syndrome in children or multisystem inflammatory syndrome in adults)?

YesNo
Are you pregnant or considering becoming pregnant?

YesNo
I have read, or had explained to me, the information fact sheet regarding the COVID-19 vaccination.*
Print Name
The updated Pfizer (Comirnaty) and Moderna (Spikevax) vaccines are the only two updated COVID-19 vaccines that are currently available in the US. The FDA is in the process of reviewing a potential third vaccine, an updated Novavax vaccine for people aged 12 and older that is designed to protect against current variants.

The CDC recommends the updated Pfizer and Moderna vaccines for everyone ages 6 months and older. The prior Pfizer and Moderna vaccines are no longer available.

People ages 5 years and older must receive one updated vaccine dose to be considered up to date.

If you previously received one or more COVID-19 vaccine dose, get one dose of either the Pfizer or Moderna updated vaccine — it does not matter which brand.

The updated vaccine can be administered two months after your last dose.

If you recently had COVID-19, you can consider waiting three months before getting your next vaccine dose. You may want to get vaccinated sooner than three months if you are at higher risk of severe illness from COVID-19 or getting it again. Talk to your provider about when you should get your next vaccine.
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