COVID-19 Vaccine Consent Form

COVID-19 Vaccine Consent Form
Patient Information
First and Last Name (Legal Name)
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Current Date*

MonthDayYear
Date
Age
Gender*
Phone*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

City

Zip
State
Drug/Food Allergies
Doctor/Prescriber Information
Doctor/Prescriber Name*
Practice Name*
City*
State*
Insurance Information
Select Insurance Carrier*
ID Number*
BIN*
PCN*
Group*
Drivers License #*
State of Issue*
Appointment Selection
Appointment*
Vaccine Selection*
Appt. Date
Please Answer the Below Questions
1. Are you sick today?*

YesNo
2. Have you ever received a COVID-19 vaccine?*

YesNo
2a. If Yes, how many doses of the COVID-19 vaccine have you received?*
2b. Do you certify that you meet the current eligibility criteria to receive an additional dose?*

YesNo
3. Have you ever had an allergic reaction to a component of the COVID-19 vaccine or a previous dose of the COVID-19 vaccine? (this would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hrs. and caused hives, swelling, or respiratory distress, including wheezing)*

YesNo
4. Have you ever had a severe allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication? (this would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hrs. and caused hives, swelling, or respiratory distress, including wheezing)*

YesNo
5. Do you have a health condition or are you undergoing treatment that makes you moderately or severely immunocompromised? (this would include, but is not limited to, treatment for cancer, HIV, receipt of an organ transplant, immunosuppressive therapy or high-dose corticosteroids, CAR-T-cell therapy, hematopoietic [HTC], or moderate or severe primary immunodeficiency)*

YesNo
6. Have you received the COVID-19 vaccine before or during hematopoietic cell transplant (HCT) or CAR-T-cell therapies?*

YesNo
7.Check all that apply to you:*

Have a history of myocarditis or pericarditisHave a history of Multisystem Inflammatory Syndrome (MIS-C or MIS-A)Have a history of immune-mediated syndrome define by thrombosis and thrombocytopenia, such as heparin-induced thrombocytopenia (HIT)Have a history of thrombosis with thrombocytopenia syndrome (TTS)Have a history of Guillian-Barre Syndrome (GBS)Have a history of COVID-19 disease within the past 3 monthsNone of the Above
I certify that I am at least 18 years old or that I am the legal guardian of the patient. I hereby give my consent to the staff of Sona Pharmacy to administer vaccine(s) that I have requested. I understand that it is not possible to predict all possible side effects or complications associated with vaccines. I understand the risks and benefits associated with the above vaccine(s) and have received, read and/or had explained to me the Emergency Use Authorization (EUA) on the vaccine(s)I have elected to receive. I also acknowledge that I have had a chance to ask questions. I, on the behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Sona Health, Inc., its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any claims arising out of, in connection with, or in any way related to the administration of the vaccines listed above. I authorize Sona Health, Inc., as applicable, to release my medical or other information to, or through, the COVID Vaccine Management System to my healthcare professionals, Medicare, Medicaid, or other third-party payer as necessary to effectuate care or payment, submit a claim to my insurer for the above requested vaccine(s), and request payment of authorized benefits to be made on my behalf to Sona Health, Inc., as applicable, with respect to the above requested items and services.*

Clear
(Parent or Guardian if patient is a minor)
Should be Empty:

COVID-19 Vaccine Consent Form

Patient Information

Doctor/Prescriber Information

Insurance Information

Appointment Selection

Please Answer the Below Questions