Office Influenza & Covid-19 Vaccination Consent Form 2023

COVID-19 Vaccination Program

Immunization Consent and Appointment System

COVID-19 Vaccine For Anyone 6 months and older

Bivalent Booster doses are available for eligible patients age 5 years of age and older.

Please have your ID and health insurance information on hand (if applicable), you will be asked to provide this information during registration.

If you experience difficulties, please contact 915-533-3414 (Mon-Fri 8A-5P)

Which vaccine(s) are you requesting? (select as many as apply)*

COVID-19 Vaccine and/or Booster

Select Appointment Location & Time

Begin your appointment selection by choosing the Immunize El Paso location you'd like to visit.
Select Location*
San Juan Clinic - 6292 Trowbridge, 79905
Downtown Clinic - 513 W. San Antonio, Ste B 79901*
Eastside Clinic - 1400 George Dieter, Ste 225 79936*

Patient Registration
Who are you completing this form for? For children, a parent or guardian must complete this form. *
Will you be attending the clinic with your child or dependent?*

YesNo
Patient Name*

First NameMiddle NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Gender*
Phone Number*

Area CodePhone Number
Personal email address*

Confirmation Emailexample@example.com
Race*
Please describe your ethnicity*
Parent, Guardian, Or Individual of Record*

First NameMiddle NameLast Name
Texas Vaccines for Children(TVFC)Program Patient Eligibility*

Health Insurance Information

If you are insured, we ask for insurance information so Immunize El Paso can be reimbursed for the cost and administration of the vaccine through your insurance company. If your insurance is not listed below, we are unable to process claims through your insurance.
Do you have health insurance?*
Select Your Insurance:*
Patient Social Security Number*
Member ID Number*
Group Number*
To whom is this policy issued:*
Policy Holder Name*

First NameLast Name
Policy Holder SSN*
State/GVMT Issued ID*

Browse Files

Cancelof
Photo of insurance card - FRONT*

Browse Files

Cancelof
Photo of insurance card - BACK*

Browse Files

Cancelof

Pneumonia Vaccine

Based on your responses you may be eligible for a pneumococcal pneumonia vaccine covered by your insurance.
Are you interested in receiving a pneumonia vaccine?
What is your age group?
Have you had a pneumonia containing vaccine in the last 12 months?
Do you have one of the following medical conditions: alcoholism, chronic heart, liver or lung disease, chronic renal failure, cigarette smoking, cochlear implant, diabetes mellitus, HIV infection, leukemia, lymphoma, sickle cell disease, solid organ transplant.
Have you received a pneumonia containing vaccine in the last 12 months?
The pneumonia vaccine is not indicated.
The pneumonia vaccine is indicated. Please advise the clerk when you arrive.

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VFC Cost

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Bivalent Booster Authorized
- Moderna COVID-19 Vaccine, Bivalent Booster authorized for use in people ages 6 years and older.
- Pfizer-BioNTech COVID-19 Vaccine, Bivalent Booster authorized for use in people ages 5 years and older
- Authorized as single booster dose administered at least 2 months after either:
- Completion of primary vaccination with any authorized or approved monovalent COVID-19 vaccine, or – Receipt of the most recent booster dose with any authorized or approved monovalent COVID-19 vaccine
Routine Booster Guidance

CDC recommends booster doses for recipients of the Pfizer, Moderna or J&J/Janssen COVID-19 vaccines at this time. Mixing and matching vaccine brands is now authorized by the Food and Drug Administration or recommended by the CDC.

Pfizer: 5 months after primary series

Moderna: 5 Months after primary series

Janssen: 2 Months after primary series

Currently, CDC is recommending that only certain people receive an additional dose. This includes:

• The CDC now recommends that children ages 5 through 11 years should receive a booster shot 5 months after their initial Pfizer COVID-19 vaccination series.
• Moderately or severely immunocompromised children 5-11 years of age are now recommended to receive an additional dose of the Pfizer vaccine 28 days after their second dose. A booster dose is not authorized for children in this age group at this time.
• Adolescents 12–17 years of age are recommended to receive a single booster dose of Pfizer COVID-19 vaccine.
• Individuals 12 years and older who received the Pfizer COVID-19 vaccine as their primary series can now receive a single booster dose 5 months after completing the primary series.
• Moderna Boosters for anyone 18yrs of age and older.

Guidance for COVID-19 vaccination for moderately or severely immunocompromised individuals:

CDC clarified existing guidance to confirm that those who previously received an mRNA COVID-19 vaccine (Pfizer or Moderna) should receive a total of 4 doses: a primary series of 3 doses of an mRNA vaccine, plus 1 booster dose of an mRNA vaccine (4th dose).

CDC provided new guidance that:
- People who received the Johnson & Johnson COVID-19 vaccine should receive a total of 3 doses:
  1 J&J dose, followed by 1 additional mRNA dose at least 28 days later, then 1 booster dose at least 2 months after the 2nd (additional) dose.
  mRNA vaccines are preferred for the booster.
- People who received a 3-dose mRNA COVID-19 vaccination series should receive the booster dose 3 months after the primary series (instead of 5 months after the primary series).
The Food and Drug Administration (FDA) authorized a second booster dose of either the Pfizer or the Moderna COVID-19 vaccines for individuals 50 years and older and certain immunocompromised individuals. Following this, the Centers for Disease Control and Prevention (CDC) has updated its clinical recommendations to include the following:
- A second booster dose of the Pfizer or Moderna COVID-19 vaccine may be administered to individuals 50 years of age and older at least 4 months after receipt of a first booster dose of any authorized or approved COVID-19 vaccine.
- A second booster dose of the Pfizer COVID-19 vaccine may be administered to certain immunocompromised individuals (see below) 12 years of age and older at least 4 months after receipt of a first booster dose of any authorized or approved COVID-19 vaccine.
- A second booster dose of the Moderna COVID-19 Vaccine may be administered to certain immunocompromised individuals 18 years of age and older at least 4 months after the first booster dose of any authorized or approved COVID-19 vaccine.
- In addition, adults who received a primary vaccine and booster dose of Johnson & Johnson’s Janssen COVID-19 vaccine at least 4 months ago may now receive a second booster dose using an mRNA COVID-19 vaccine.
- Immunocompromised individuals include people with a range of conditions, such as recipients of organ or stem cell transplants, people with advanced or untreated HIV infection, recipients of active treatment for cancer, people who are taking some medications that weaken the immune system, and others.
You should talk to your healthcare provider about your medical condition, and whether getting an additional dose is appropriate for you prior to getting immunized.
Vaccination Consent Form
Influenza Vaccine Consent

You are allowed to volunteer to participate in the seasonal Flu vaccinations, which may include needle injection. If you decide to participate in this vaccination process, please sign this form. You will be given a copy of this form to keep upon request.

1. I agree that the person named above will get the inactivated influenza vaccine, the pneumococcal conjugate vaccine, and/or the pneumococcal polysaccharide vaccine.

2. I received or was offered a copy of the Vaccine Information Statement (VIS)

3. I know the risks of vaccine-preventable diseases.

4. I know the benefits and risks of the vaccine to be administered.

5. I have had a chance to ask questions about the diseases, the vaccine, and how the vaccine is given.

6. I know that the person named above will have a vaccine put in his/her body.

7. I am an adult who can legally consent for the person named below to get vaccines. I freely and voluntarily give my signed permission for each vaccine.

8. I authorize release of any medical or other information to process the claim. I also request payment of government benefits to the party who accepts assignment.

9. The patient (or patient’s guardian) is ultimately responsible for the payment for the treatment of care. We will bill your insurance on your behalf, however, you are required to provide the most current and updated insurance information. You are responsible for any applicable co-pays, deductibles & co-insurance payments associated with this vaccine administration.

I hereby certify that I have read and understand the information provided on this form. I have been given information about this vaccination process and its risks and benefits and have had the opportunity to ask questions and to have my questions answered to my satisfaction. I freely give my consent to receive this vaccination. I hereby release and hold harmless Immunize El Paso, ProAction, Inc, its, staff, employees, officers and directors, from liability, damage, or claim arising from any injury or complication that may result from receiving this vaccination.
COVID-19 Vaccine Consent

I have received, read, and understand the COVID-19 Vaccine Information provided by ProAction, Inc. I hereby authorize ProAction, Inc. and the practitioners employed by or contracted with ProAction, Inc. (each, a “Provider”) to administer the Vaccine I have requested above as a two-dose regimen series administered in accordance with manufacturer and CDC recommendations (the “Services”). The scope of this consent includes discussion about the vaccine(s) and its administration between ProAction, Inc., and other health care professionals for purposes of care and treatment. I understand that I may withdraw this consent at any time by making a request in writing.

I acknowledge that I have been informed about, the following:

• The goal of the Services is to administer the Vaccine I requested.

• The Provider(s) will provide me with additional information about any risks associated with the Services, depending on my specific diagnoses and health status.

• Administering Vaccines is not an exact science, and there are no guarantees as to the results of the Services that may be provided to me.

• The nature and purpose of the Services, expected benefits, potential known and unknown complications, the likelihood of achieving goals, and relative risks that may arise from the Services, along with the relevant risks and consequences of no treatment.

I understand the benefits and risks of the Vaccine, and I expressly consent, request, and authorize the administration of the Vaccine. On behalf of myself, my heirs, and personal representatives, I hereby release and hold harmless Pro-Action, Inc, each Provider, and the applicable staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors, and employees from any and all liability or claims, whether known or unknown, arising out of, in connection with, or in any way related to the Services. I acknowledge that: (a) I understand the purposes/benefits of my state’s vaccination registration (“State Registry”) and my state’s health information exchange (“State HIE”); and (b) the Provider may disclose my vaccination information to the State Registry, to the State HIE, or through the State HIE to the State Registry, for purposes of public health reporting, or to my healthcare providers enrolled in the State Registry and/or State HIE for purposes of care coordination.

I further authorize the applicable Provider to (a) release my medical or other information, including my communicable disease (including HIV), mental health and drug/alcohol abuse information, to, or through, the State HIE to my healthcare professionals, Medicare, Medicaid, or other third-party payers as necessary to effectuate care or payment; (b) submit a claim to my insurer for the Services, and (c) request payment or authorized benefits be made on my behalf to the applicable Provider concerning the Services. I acknowledge that depending upon my state’s law, I may prevent, by using a state-approved opt-out form or, as permitted by my state law, an opt-out form (“Opt-Out Form”) furnished by the Provider: (a) the disclosure of my vaccination information by the Provider to the State HIE and/or State Registry; or (b) the State HIE and/or State Registry from sharing my vaccination information with any of my other healthcare providers enrolled in the State Registry and/or State HIE. The Provider will, if my state permits, provide me with an Opt-Out Form.

I understand that I may need to consent, depending on my state’s law, and to the extent so required, I hereby do consent by signing below to the Provider reporting my vaccination information to the State HIE, or through the State HIE and/or State Registry to the entities and for the purposes described in this Informed Consent Form. Unless I provide the Provider with a signed Opt-Out Form, I understand that my consent will remain in effect until I withdraw my permission and that I may withdraw my consent by providing a completed Opt-Out Form to the Provider and/or my State HIE, as applicable. I understand that even if I do not consent or if I withdraw my consent, my state’s laws may permit certain disclosures of my vaccination information to or through the State HIE as required or permitted by law. Photocopies/electronic transmissions/faxes of this consent and any signatures are to be considered as valid originals.

MY SIGNATURE BELOW INDICATES THAT I VOLUNTARILY AGREE TO ALL OF THE ABOVE AND THAT THE NATURE OF THIS CONSENT WAS EXPLAINED TO ME AND THAT I HAD THE OPPORTUNITY TO ASK ANY AND ALL QUESTIONS REGARDING THE ABOVE AND MY QUESTIONS HAVE BEEN ANSWERED TO MY SATISFACTION. I UNDERSTAND THE BENEFITS AND RISKS OF THE VACCINE AND I EXPRESSLY CONSENT, REQUEST, AND AUTHORIZE THE ADMINISTRATION OF THE VACCINE. I HAVE BEEN PROVIDED WITH THE CDC’S VACCINE INFORMATION SHEET(S) OR THE EMERGENCY USE AUTHORIZATION (EUA) PATIENT FACT SHEET CORRESPONDING TO THE VACCINE THAT I AM RECEIVING.
Pneumococcal Consent

I have read, or had explained to me, the Vaccine Information Statement about pneumococcal vaccination. I have had a chance to ask questions, which were answered to my satisfaction, and I understand the benefits and riskd of the vaccinations as described. I request that the pneumococcal vaccination be given to me (or the person named above for whom I am authorized to make this request). I authorized the release of any medical or other information necessary to process a Medicare or other insurance claim or for other public health purpose.
Signature*

Clear
Date Of Service*

MonthDayYear
Date
Influenza Vaccine Administered*
Lot Number Influenza*
Route & Site Influenza*
Pneumonia Vaccine Administered *
Lot Number Pneumonia*
Route & Site Pneumonia*
VIS Date

MonthDayYear
Date
Date VIS Given

MonthDayYear
Date
COVID-19 Vaccine Administered*
Vaccine Dose COVID-19*
Lot Number COVID-19*
Route & Site COVID-19 *
Given by*
Place of Service*
Should be Empty:

	Yes	No
Are you currently under quarantine or isolation orders for COVID-19?
Do you have any COVID-19 or influenza-like symptoms? (Fever, cough, loss of sense of smell or taste, breath, sore throat, runny nose or congestion, nausea or vomiting, diarrhea)
Has a physician or medical provider indicated you should NOT receive the Influenza vaccine?
Have you ever had a serious reaction to a vaccine or a severe allergic reaction that required going to ER?
Are you allergic to egg?

	Yes	No
Is the person to be vaccinated currently under quarantine or isolation orders for COVID-19?
Do you have any COVID-19 or influenza-like symptoms? (Fever, cough, loss of sense of smell or taste, breath, sore throat, runny nose or congestion, nausea or vomiting, diarrhea)
Has a physician or medical provider indicated that the person being vaccinated should NOT receive the COVID-19 vaccine?
Have you ever had a serious reaction to a vaccine or a severe allergic reaction that required going to ER?

Screening Questionnaire

Select Appointment Location & Time

Patient Registration

Health Insurance Information

Pneumonia Vaccine

Vaccination Consent Form