COVID Consent Form

COVID Vaccine:
** Please do not fill this form out until it is the day you want to come for the vaccine, or the information will no longer be accurate **

*If this is your first time receiving a vaccine from us, please also fill out the HIPAA form*
Please check below which vaccine you are receiving today:

ModernaPfizer
Select the arm you would like to receive the vaccine in:

Left ArmRight Arm
Full Name*

First NameLast Name
Date of Birth*
Are you sick today with a fever?

YesNo
Do you have allergies to medications, food, a vaccine component, or latex?

YesNo
Have you ever had a serious reaction after receiving a vaccine?

YesNo
If you answered yes to any of the above, please let us know which allergy you have and what the reaction was.
Do you have any of the following:

long term health problem with your heart, lung, and/or kidneydiabetes or other metabolic diseaseasthmablood disorderno spleencochlear implantspinal fluid leaka seizure, brain, or other nervous system problemlong term aspirin therapycancerleukemiaHIV/AIDsother immune system problema parent, brother, or sister with an immune system problemnone of the above
In the past 6 months, have you taken medication that affects your immune system, such as prednisone (or other steroids); anticancer drugs or radiation treatment; or drugs to treat rheumatoid arthritis, Crohn's Disease, or psoriasis?

YesNo
Have you ever been diagnosed with a heart condition (myocarditis or pericarditis) or have you had Multisystem Inflammatory Syndrome (MIS-A or MIS-C) after a COVID Infection?

YesNo
In the past year have you received immune gamma globulin, blood/blood products, or an antiviral drug?

YesNoI don't Know
Are you pregnant?

YesNo
Have you received any vaccines in the last 4 weeks?

YesNoI don't Know
Have you ever felt dizzy or faint before, during, or after a shot?

YesNo
Are you anxious about getting a shot today?

YesNo
Signature*

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COVID Vaccine: