COVID-19 VACCINE INFORMED CONSENT FORM
Patient Information
Full Name (First MI Last)
*
Date of Birth
*
/
Month
/
Day
Year
Date
Age
*
Email
example@example.com
Phone
*
Address
*
Address
Street Address Line 2
City
State
Zip Code
Gender
*
Male
Female
Race
*
Please Select
African American
American Indian
Asian
Caucasian
Native Hawaiian/Other Pacific Islander
Other
Prefer not to answer
Ethnicity
*
Please Select
Hispanic/Latino
Non-Hispanic/Latino
Unknown
Prefer not to answer
Primary Care Doctor
City/State
How many doses of COVID-19 vaccine have you received?
*
0
1
2
3
Other
Date of last dose
*
/
Month
/
Day
Year
Date
Which original vaccine did you receive?
*
Pfizer (12+)
Pfizer Pediatric (5-11)
Moderna
Janssen
Other
A booster dose is recommended for you if it has been at least two (2) months since your first dose. The CDC recommends receiving your booster dose from the same manufacturer as your primary dose(s), but you may opt to receive a dose from a different manufacturer.
If you received Janssen for your original dose as well as your first booster dose, you are eligible to receive a second booster dose of Moderna or Pfizer at least 4 months after your first booster dose.
Which vaccine would you prefer to receive for your first dose?
*
Pfizer
Moderna
Janssen
Which booster vaccine would you prefer to receive?
Pfizer
Moderna
Please mark any of the following conditions that you meet
*
I have been receiving active cancer treatment for tumors or cancers of the blood
I have received an organ transplant and am taking medicine to suppress the immune system
I have received a stem cell transplant within the last 2 years or am taking medicine to suppress the immune system
I have moderate or severe primary immunodeficiency (such as DiGeorge syndrome, Wiskott-Aldrich syndrome)
I have advanced or untreated HIV infection
I have active treatment with high-dose corticosteroids or other drugs that may suppress my immune response
None of the above
IMMUNOCOMPROMISED
A third dose is recommended at least 28 days after the date of the second dose. You will receive the vaccine from the same manufacturer as you received for your primary series.
A booster dose is recommended at least 3 months after the date of your last dose. Depending on your age, you may choose which manufacturer’s vaccine you would like to receive for the booster dose. Pfizer is approved for those 12 or older; Moderna is approved for those 18 or older.
Which booster dose would you prefer to receive?
*
Pfizer
Moderna
You are eligible to receive a second booster dose at least 4 months after the date of your last dose. Depending on your age, you may choose which manufacturer’s vaccine you would like to receive for the booster dose. Pfizer is approved for those 12 or older; Moderna is approved for those 18 or older.
Which booster dose would you prefer to receive?
*
Pfizer
Moderna
NOT IMMUNOCOMPROMISED
A booster dose is recommended at least 5 months after the date of your last dose. Depending on your age, you may choose which manufacturer’s vaccine you would like to receive for the booster dose. Pfizer is approved for those 12 or older; Moderna and Janssen are approved for those 18 or older.
Which booster dose would you prefer to receive?
*
Pfizer
Moderna
You are eligible to receive a second booster dose at least 4 months after the date of your last dose.
Which booster dose would you prefer to receive?
*
Pfizer
Moderna
You do not qualify for an additional dose at this time.
We do not have that vaccine available at this time.
You are not eligible for this manufacturer's vaccine.
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Screening Questions
Please select the correct option below.
Do you feel sick today?
*
Yes
No
Don't Know or N/A
In the past two weeks, have you tested positive for COVID-19 or are you currently being monitored for COVID-19?
*
Yes
No
Don't Know or N/A
In the past two weeks, have you had a known exposure with anyone who tested positive for COVID-19?
*
Yes
No
Don't Know or N/A
Have you been diagnosed with Multisystem Inflammatory Syndrome (MIS-C or MIS-A) after a COVID-19 infection?
Yes
No
Don't know or N/A
Have you had a new onset of fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, nausea, vomiting or diarrhea?
*
Yes
No
Don't Know or N/A
Do you have an allergy to any food, medication or vaccine?
*
Yes
No
Don't Know or N/A
Please specify allergy
Have you ever had a serious reaction or fainted after receiving any vaccination?
*
Yes
No
Don't Know or N/A
Do you carry an EpiPen?
*
Yes
No
Don't Know or N/A
Do you have a bleeding disorder or take a blood thinner?
*
Yes
No
Don't Know or N/A
Have you ever had a seizure, brain disorder, or Guillain-Barre Syndrome?
*
Yes
No
Don't Know or N/A
Do you have a weakened immune system (i.e., HIV infection, cancer) or take immunosuppressive drugs or therapies?
*
Yes
No
Don't Know or N/A
Do you have a history of myocarditis or pericarditis?
*
Yes
No
Don't Know or N/A
Have you received hematopoietic cell transplant (HCT) or CAR-T-cell therapies since receiving COVID-19 vaccine?
*
Yes
No
Don't Know or N/A
FOR WOMEN: Are you currently pregnant or breastfeeding?
*
Yes
No
Don't Know or N/A
Pfizer (12+) VIS
|
Pfizer (5-11) EUA
|
Moderna EUA
|
Janssen EUA
Notice of Privacy Practices
Acknowledgements
*
I attest that the answers provided here are accurate to the best of my knowledge.
I understand the benefits and risks of the vaccination(s) as described in the Vaccine Information Sheet (VIS) or Emergency Use Authorization (EUA), a copy of which I was provided with this Consent & Release. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent & Release.
I have received a copy of the notice of Privacy Practices. I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy & of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.
Insurance Information
I hereby authorize the pharmacy to bill my insurance on my behalf for the COVID-19 vaccine administration fee & receive payment.
Please mark here if you do not have insurance and provide your social security number or driver's license number.
Social Security Number
Driver's License Number
Insurer
Member #
Rx Group
BIN #
PCN #
Signature of Patient to Receive Vaccine (or Signature of Power of Attorney or Legal Guardian)
Clear
Date
-
Month
-
Day
Year
Date
Parent/Guardian Name
Relationship to patient
After submitting, you will be redirected to schedule your appointment. Please make sure to confirm your appointment so we save your spot on our schedule. If you are scheduling for COVID-19 and another vaccine, please only make the COVID-19 appointment. If there are no appointments available for the vaccine you need, please check back.
By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.
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