COVID-19 Vaccine Consent Form

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The COVID-19 vaccine will reduce the risk of being suffering from the new type of Coronavirus disease as known as COVID-19. Please be aware that the vaccine is not completely effective like all other medicines. It can take a few weeks for your body to build up protection from the vaccine. There is always a chance to get infected by Coronavirus even with the vaccine; however, the vaccine lessens the severity of any infection. Two doses will reduce the chance of being seriously ill and reduce the risk of death due to Coronavirus. You still need to follow the health instructions in your workplace and in public areas, such as wearing a mask and keeping the distance from others after you received the COVID-19 vaccine. The vaccine has some side effects as the other vaccines/medicines, but not everyone gets them. The most likely side effects that you may experience from the vaccine Fever Pain at the injection site Redness and hardness of the skin at the injection site Headache Muscle aches or pain Joint aches or pain Fatigue (tiredness) Nausea/vomiting Chills Underarm gland swelling on the side of study vaccination If you think you are experiencing any side effects, please remain calm and see your doctor immediately. If you are currently pregnant or planning to get pregnant or your partner is planning to get pregnant; please see your doctor before getting vaccinated.
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Do you have any of the followings? (select all that apply)* This field is required.
Lung disease
Heart disease
Asthma
Kidney Disease
Diabetes
Anemia
Blood disorder
None
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* This field is required.If any allergies please specify below
Yes
No
If yes, please specify below.
Do you have allergies to latex, food, medications, or vaccine components? (such as eggs, thimerosal, gelatin, neomycin, phenol, or bovine protein)?
Did you ever experience any serious reaction after getting a vaccine?
In the past year, did you receive a transfusion of blood or blood products, or get injected immune (gamma) globulin or any antiviral drug?
Did you have any brain or other nervous system problems?
Have you get vaccinated in the last 4 weeks?
Are your pregnant or planning to get pregnant or your partner is planning to get pregnant?
Do you have allergies to latex, food, medications, or vaccine components? (such as eggs, thimerosal, gelatin, neomycin, phenol, or bovine protein)?
Did you ever experience any serious reaction after getting a vaccine?
In the past year, did you receive a transfusion of blood or blood products, or get injected immune (gamma) globulin or any antiviral drug?
Did you have any brain or other nervous system problems?
Have you get vaccinated in the last 4 weeks?
Are your pregnant or planning to get pregnant or your partner is planning to get pregnant?
Yes
No
If yes, please specify below.
Yes
No
If yes, please specify below.
Yes
No
If yes, please specify below.
Yes
No
If yes, please specify below.
Yes
No
If yes, please specify below.
Yes
No
If yes, please specify below.
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Do you have immunocompromised condition? (select all that apply)
Cancer
Leukemia
Lymphoma
HIV/AIDS
Transplant
Asplenia
CSF leak
Cochlear implant
None
5
Have you ever tested positive for COVID-19?* This field is required.
Yes
No
6
In the last 14 days, have you contacted with a person who was confirmed to have COVID-19?* This field is required.
Yes
No
Not sure
7
Do you have any of the followings?* This field is required.
Cough
Cold
Fever
Shortness of breath
Sore throat
Loss of smell/taste
Abdominal pain/diarrhea
Abnormal bruising or bleeding/eye redness
None of the above
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Full Legal Name as you would like to find on Docket* This field is required.
First Name
Last Name
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Phone Number* This field is required.Cell phone # is preferred if you would like to use Docket or any electronic app.
Please enter a valid phone number.
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Birth Date* This field is required.
Month
Day
Year
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Email* This field is required.
example@example.com
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Please upload a picture of your Rx insurance card, and or Medicare cards. If you cannot upload, please input social security number on the next field.Insurance Information:
14
Last 4 digits of Social Security #* This field is required.
15
Patient Race* This field is required.
White
Black/African American
Asian
American Indian or Native Island Pacific
Other race
Prefer not to specify
16
Patient Ethnicity* This field is required.
Not Hispanic
Hispanic
Please choose one of the followiing:
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Vaccine:* This field is required.Please choose which dose you will be receiving.
Moderna 1st dose
Moderna 2nd dose
Moderna 3rd dose
Moderna 4th dose
Pfizer 1st dose
Pfizer 2nd dose
Pfizer 3rd dose
Pfizer 4th dose
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Please choose which arm for administration of vaccine:* This field is required.
Left Arm
Right Arm
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Appointment Date
Date
Year
Month
Day
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By signing this form, I hereby accept that I have read and understood the acknowledgment letter provided above. I declare that the information I have provided above is correct. I am giving my full consent to get the COVID-19 vaccine of my own will.
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Signature* This field is required.
Clear
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Date* This field is required.
Date
Month
Day
Year
Should be Empty: