2022 COVID-19 Consent Form Rev 7/2022

Do you feel sick today? *

Yes No Don't Know or N/A

Have you had COVID-19 within the last three months? *

Yes No Don't Know or N/A

Do you have a history of an immune-mediated syndrome defined by thrombosis and thrombocytopenia, such as heparininduced thrombocytopenia (HIT)? *

Yes No Don't Know or N/A

Do you have a history of thrombosis with thrombocytopenia syndrome (TTS)? *

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 Pfizer (6mo-4yr) EUA Moderna (12+) EUA Moderna (6-11) EUA Moderna (6mo-5yr) EUA Janssen (18+) EUA

Notice of Privacy Practices

Acknowledgements *

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. I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.

Insurance Information

Medicaid Medicare Part B Private Insurance Please mark here if you do not have insurance to procide your social security number or driver's license number.

Medicaid Provider

Medicaid Policy/Member ID #

Medicaid #

Medicaid Group #

Medicare Part B Subscriber ID #

Medicare Part B Responsible Party

Medicare Part B Policy Holder's DOB

Date

Insurer

Subscriber ID #

Bin #

PCN

Group #

Social Security Number

Driver's License Number

Signature of Patient to Receive Vaccine (or Signature of Power of Attorney or Legal Guardian)

Clear

Date

Parent/Guardian Name

Relationship to patient

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.

COVID-19 VACCINE INFORMED CONSENT FORM

Patient Information

IMMUNOCOMPROMISED

NOT IMMUNOCOMPROMISED

Screening Questions