2022 COVID-19 Consent Form Rev 12/2022

Do you feel sick today?*

YesNoDon't Know or N/A

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

YesNoDon'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)?*

YesNoDon't Know or N/A

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

YesNoDon't Know or N/A

Have you been diagnosed with Multisystem Inflammatory Syndrome (MIS-C or MIS-A) after a COVID-19 infection?

YesNoDon'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?*

YesNoDon't Know or N/A

Do you have an allergy to any food, medication or vaccine?*

YesNoDon't Know or N/A

Please specify allergy

Have you ever had a serious reaction or fainted after receiving any vaccination?*

YesNoDon't Know or N/A

Do you carry an EpiPen?*

YesNoDon't Know or N/A

Do you have a bleeding disorder or take a blood thinner?*

YesNoDon't Know or N/A

Have you ever had a seizure, brain disorder, or Guillain-Barre Syndrome?*

YesNoDon't Know or N/A

Do you have a weakened immune system (i.e., HIV infection, cancer) or take immunosuppressive drugs or therapies?*

YesNoDon't Know or N/A

Do you have a history of myocarditis or pericarditis?*

YesNoDon't Know or N/A

Have you received hematopoietic cell transplant (HCT) or CAR-T-cell therapies since receiving COVID-19 vaccine?*

YesNoDon't Know or N/A

FOR WOMEN: Are you currently pregnant or breastfeeding?*

YesNoDon't Know or N/A

Moderna (6mo-5yr) EUA

Janssen (18+) EUA

Novavax (12+) EUA

Notice of Privacy Practices

Acknowledgements*

I attest that the answers provided here are accurate to the best of my knowledge.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 there answered to my satisfaction. I request the vaccine to be given to me or the person named above, a minor for whom I represent that I am authorized to sign the 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 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.

Insurance Information

MedicaidMedicare Part BPrivate InsurancePlease 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

UPDATED BOOSTER

Screening Questions