COVID Vaccine Consent Form

Novavax COVID Vaccine Consent Form

* Please fill out the required details below
Patient's Full Name: *

First Name Ml Last Name
Today's Date

Month Day Year
Date
Date of Birth: *

Month Day Year
Age: *
Age *
Gender: *

Male Female
Phone Number: *
Email: *
Ethnicity: *

Hispanic or Latino Non Hispanic/Latino Unknown Prefer not to answer
Race: *

African American American Indian Asian Caucasian Native Hawaiian/Other Pacific Islander Prefer not to answer
Address: *

Street Address Line 2
What dose of COVID-19 vaccine will this be? *

First Dose Second Dose
What date was your most recent COVID-19 vaccine received on? *

Month Day Year
Date
when did you receive your second dose?

Month Day Year
Date
Do you have insurance that covers vaccines?

Yes No I don't know
Indicate the person's eligibility status for the Vaccine for Children (VFC) Program

is enrolled in Medicaid does not have health insurance is American Indian or Alaskan Native (AI/AN) is underinsured (has health insurance that DOES NOT pay for vaccinations [Can only receive VFC vaccine at Federally Qualified Health Center (FQHC), rural health clinic (RHC), or local public health (LPHA)] is not eligible for the VFC program because they do not meet the above criteria

Please select the correct option below: *

	Yes	No	Don't know or N/A
Are you feeling sick today?
Have you ever received a dose of Pfizer COVID-19 vaccine?
Have you ever received a dose of Moderna COVID-19 vaccine?
Have you ever receive a dose of Jassen (Johnson & Johnson) COIVD-19 vaccine?
Have you ever had a severe allergic reaction: (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 caused hives, swelling, or respiratory distress, including wheezing.) A component of a COVID-19 vaccine, including either of the following: * Polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures
* Polysorbate, which is found in some vaccines, film coated tablets, and intravenous steroids
* A previous dose of COVID-19 vaccine
Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or injectable medication?

5. Check all that apply to you *

None of these apply to me Am a female between ages 18 to 49 years old Had a severe allergic reaction to something other than a vaccine or injectable therapy such as food, pet, venom, environmental or oral medication allergies Had COVID-19 and was treated with monoclonal antibodies or convalescent serum Diagnosed with Multisystem Inflammatory Syndrome (MIS-C or MIS-A) after a COVID-19 infection Have a weakened immune system (i.e., HIV infection, cancer) Take immunosuppressive drugs or therapies Have a bleeding disorder Take a blood thinner Have a history of herparin-induced thrombocytopenia (HIT) Am currently pregnant or breasfeeding Have received dermal fillers
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA), a copy of which I was provided with this Consent and 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, for whom I represent that I am authorized to sign this Consent and Release.
Signature of Person to Receive Vaccine & EUA/VIS (or Signature of Guardian) *

Clear
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 and 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.
Signature of Acknowledgment of Notice of Privacy Practices: *

Clear
Appointment *
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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Novavax COVID Vaccine Consent Form