COVID Vaccine Consent Form

NEW Novavax COVID Vaccine Consent Form

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

First NameMlLast Name
Today's Date

MonthDayYear
Date
Date of Birth:*

MonthDayYear
Age:*
Age*
Gender:*

MaleFemale
Phone Number:*
Email:*
Ethnicity:*

Hispanic or LatinoNon Hispanic/LatinoUnknownPrefer not to answer
Race:*

African AmericanAmerican IndianAsianCaucasianNative Hawaiian/Other Pacific IslanderPrefer not to answer
Address:*

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

First DoseSecond DoseBooster
What vaccine have you had in the past?*

PfizerModernaJohnson & Johnson
What date was your most recent COVID-19 vaccine received on?*

MonthDayYear
Date
when did you receive your second dose?

MonthDayYear
Date
Do you have insurance that covers vaccines?

YesNoI don't know
Indicate the person's eligibility status for the Vaccine for Children (VFC) Program

is enrolled in Medicaiddoes not have health insuranceis 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 or do you have a fever?
Have you ever had an allergic reaction to any vaccine (including Flu & COVID-19), vaccine ingredients (e.g. Polyethylene glycol, Polysorbate or eggs) or injectable medications in the past?
Do you have any of the following? History of myocarditis or pericarditis or a diagnosis or myocarditis or Pericarditis following a COVID-19 vaccine History of COVID-19 infection that was treated with monoclonal antibodies or convalescent serum Multisystem Inflammatory Syndrome (MIS-C or MIS-A) after a COVID-19 infection Bleeding disorder or take blood thinners * History of heparin-induced thrombocytopenia (HIT) * Received dermal fillers * History of Guillain-Barre Syndrome (GBS)

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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