COVID19 Vaccine Consent Form

Moderna COVID-19 Vaccine Consent Form
Select an appointment time. Appointments will be held at Brehme Drug, 220 East Main Street, Manchester IA 52057.*
Please re-enter the appointment date and time selected above.*

MonthDayYear
Date
Hour MinutesAM/PM Option

Patient Information

Vaccine Recipient
Vaccine Recipient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Sex at Birth*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Race*
Ethnicity*
Primary Care Provider Name
Mother's Maiden Name
Emergency Contact Name

First NameLast Name
Emergency Contact Relation
Emergency Contact Phone Number
Please enter a valid phone number.

Select the dose receiving:*

1st Dose2nd DoseAdditional dose (immunocompromised only)Updated/Bivalent Booster Dose
If applicable, which vaccine product did you receive last?

PfizerModernaJanssenNovavax
Number of COVID-19 Vaccine Doses Received
ex: 0, 1, 2, 3, 4, or 5
Date of last COVID-19 Vaccine

MonthDayYear
Date

Screening Questions*

	Yes	No	Unsure
Are you feeling sick today?
Have you ever had an allergic reaction to a component of the COVID-19 vaccine, including polyethylene glycol (PEG) or polysorbate or a previous dose of COVID-19 vaccine?
Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication? (This would include a severe allergic reaction [eg. anaphylaxis] that required treatment with epinephrine or EpiPen(R) 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.)
Have you ever had a severe allergic reaction (eg. anaphylaxis) to something other than a component of COVID-19 vaccine, polysorbate, or any vaccine or injectable medication? This would include food, pet, venom, environmental, or oral medication allergies.
Does the person to be vaccinated have a health condition or undergoing treatment that makes them moderately or severely immunocompromised? This would include, but not limited to, treatment for cancer, HIV, receipt of organ transplant, immunosuppressive therapy, or high-dose corticosteroids, CAR-T-cell therapy, hematopoietic cell transplant (HCT), or moderate or severe primary immunodeficiency.
Have you previously received a COVID-19 vaccine before or during hematopoietic cell transplant (HCT) or CAR-T-cell therapies?
Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?
Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
Do you have a bleeding disorder or are you taking a blood thinner?
Do you have dermal fillers?
Do you have a history of myocarditis or pericarditis?
Have you been diagnosed with Multisystem Inflammatory Syndrome?
Do you have a history of heparin-induced thrombocytopenia (HIT) or thrombosis with thrombocytopenia syndrome (TTS)?
Do you have a history of Guillain-Barre Syndrome (GBS)?
Have you had COVID-19 infection in the past 3 months?

If you have received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19, when did you receive antibody therapy?

MonthDayYear
Date

Consent (check each box below after reading)*

	Check each box
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet, a copy of which I was provided with this Consent Form. I have had a change 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 Form.
I understand that at this time, some COVID-19 vaccines require 2 doses given 21-28 days apart dependent on the manufacturer. If this is my first dose of the COVID-19 vaccine and a second dose is required (Pfizer, Moderna, or Novavax), I intend to receive a second dose of the same vaccine in accordance with the timeframe specified in the Fact Sheet to complete the series.
I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.
I understand that I will be receiving the vaccination at no cost to me.

The vaccine is available to anyone, no matter if insured or uninsured. Please check only one of the following.*

	Check one
If INSURED, check this box attesting to bringing in your prescription & medical insurance cards. By selecting, you are also authorizing the pharmacy to bill your insurance on your behalf - understanding you will not incur any costs.
If UNINSURED, you must check this box to attest that the following information is true and accurate: I do not have any insurance, including but not limited to, Medicare, Medicaid, or any other private or government-funded benefit plan.

For UNINSURED patients, please select one of the following that you will present at the pharmacy. (This is needed, but not required, to have your vaccine administration fee paid for by the United States Health Resources & Services Administration's COVID-19 Program.)

	Check one
Social Security Number
State identification number & state of issuance
Driver's license number & state of issuance

Signature of Person to Receive Vaccine & EUA/VIS (or Signature of Parent/Guardian if Patient is < 18 years old):*

Clear
Date Signed*

MonthDayYear
Date
Take photo of your Medicare A/B Card or prescription insurance card (if you do not have Medicare).
Should be Empty:

Moderna COVID-19 Vaccine Consent Form

Patient Information