Universal Vaccine Consent Form
Please select your appointment time
*
Vaccine Recipient Name
*
First Name
Middle Initial
Last Name
Vaccine Recipient Physical Address
*
Street Address
City
State Initials
Postal / Zip Code
Date of Birth
*
/
Month
/
Day
Year
You must be 12 years or older to receive the primary series vaccine and 18 years or older for the updated bivalent booster vaccine
Age
Enter age of vaccine recepient
Gender
*
Please Select
Male
Female
Race
*
Please Select
White
American Indian or Alaska Native
Asian
Black or African-American
Native Hawaiian or Other Pacific Islander
Other
This information is required for vaccine reporting
Ethnicity
*
Please Select
Hispanic/Latino
Non Hispanic/Latino
This information is required for vaccine reporting
Vaccine Recipient Phone Number
*
Please enter a valid phone number.
Emergency Contact Name
*
Relationship to Emergency Contact
*
Phone Number of Emergency Contact
*
Select which vaccine(s) you would like to receive today.
*
Influenza (3years to 64 years)
Influenza (65 and older)
Pneumonia 20
Shingles
Tetanus/Whooping Cough
RSV (60 and older)
Moderna Spikevax (12 and older)
ALL Vaccine Screening Questions
*
Yes
No
Not Applicable
1. Are you feeling sick or experiencing a moderate to high fever today?
2. Do you have any allergies to medications, food (i.e., eggs), latex, vaccine components (e.g. neomycin, formaldehyde, gentamicin, thimerosol, bovine protein, phenol, polymyxin, gelatin, polysorbate,polyethylene glycol, baker's yeast or yeast)?
3. Have you ever had a serious reaction to any vaccination, including fainting or feeling dizzy?
4. Have you ever had a health problem with lung, heart, kidney, or metabolic disease (e.g. diabetes, asthma, or a blood disorder?
5. Have you ever had a seizure disorder for which the patient is on seizure medication(s), a brain disorder, Guillain-Barre syndrome ( a condition that causes paralysis) or other nervous system problems?
6. Are you pregnant or breastfeeding?
COVID Vaccine Screening Questions
Yes
No
Not Applicable
1. Are you currently on quarantine due to an exposure to COVID-19?
2. Are you currently on isolation due to being diagnosed with COVID-19 in the last 10 days?
3. Have you received passive antibody therapy (monoclonal antibodies/covalescent serum) as treatment for COVID-19 in the last 90 days?
[note: monoclonal antibodies does NOT include antibiotics that you would be prescribed and filled at a pharmacy]
4. Do you have a weakened immune system caused by something such as HIV, cancer, or do you take
immunosuppressive drugs/therapies (e.g. steroid, chemotherapy, radiation)?
Other Questions
*
Yes
No
Not Applicable
1. Have you been told you have pre-diabetes
2. Are you interested in learning how to delay diagnosis of diabetes
Medicare Questions
*
Yes
No
Not Applicable
1. Do you have a diagnosis of type 2 diabetes
2. Have you received a pair of diabetic shoes in the last year?
Have you have the following vaccinations
*
Yes
No
1. Pneumonia
2. Shingles
3. Tetanus/Whooping Cough
COVID-19 Vaccine Manufacturer for the first/second dose you received
*
Please Select
Moderna
Pfizer
Janssen/Johnson&Johnson
None
Date of first dose
*
/
Month
/
Day
Year
Date of second dose (if applicable)
/
Month
/
Day
Year
Date of 1st Booster dose (if applicable)
/
Month
/
Day
Year
Date of 2nd Booster dose (if applicable)
/
Month
/
Day
Year
Date of 3rd Booster dose (if applicable)
/
Month
/
Day
Year
Insurance Information
Rx BIN Number
Rx PCN Number/Processor Control Number
Rx Group Number/GRP Number
RX ID Number
Medicare Benefits Number
For Medicare Patients Only. Enter letters and numbers as shown in the image.
Which arm would like the vaccine administered?
*
Left
Right
Select Arm
For uninsured patients, please select at least one of the following that you will bring with you to your appointment.
Social Security Number
State identification number and state of issuance
Driver's license number and state of issuance
Enter ID number/Drivers License Number/Social Security Number
Enter one of the ID numbers in the box.
Name of Person Completing This Form
*
Relationship to Patient (if not patient)
By signing this form, I attest that all information I have provided on this form is true and accurate, thereby qualifying me to receive a COVID-19 vaccine/booster dose.
*
Date Signed
*
/
Month
/
Day
Year
Date
SUBMIT (required)
Should be Empty: