Vaccine Consent Form
1301 Justin Rd Suite 212, Lewisville, TX 75077
Date of Birth
Street Address Line 2
State / Province
Postal / Zip Code
American Indian/Alaskan Native
Native Hawaiian/Pacific Islander
Which Vaccine are you requesting?
Moderna Bi-Valent (Only used for booster shot)
Pfizer Bi-Valent (this is the new booster vaccine for omicron variant)
Novavax (This is for persons who are getting first time vaccine for covid)
Are You feeling sick today?
Have you previously received a dose of COVID-19?
NO. (This is my first vaccine)
How many doses of COVID-19 vaccine have you recieved?
Is the person to be vaccinated have a health condition or undergoing treatment that makes them moderately or severely immunocompromised?
Are you Pregnant or planning to become Pregnant?
Has the person to be vaccinated ever had an allergic reaction to a previous dose of COVID-19 or any component of any vaccine?
Check all that apply to the person to be vaccinated:
Have a history of myocarditis or pericarditis
Have a history of MIS-C or MIS-A
History of an immune-mediated syndrome defined by thrombisis and thrombocytopenia
Have Guillan-Barre Syndrome
History of COVID-19 within the past 90 days?
None of the above
FOR OFFICE USE ONLY
Vaccine Admin Signiture_______________________________ Vaccine Name:_________________________________________ LOT:_____________________________EXP:__________________
Should be Empty: