COVID Vaccine Consent Form

COVID Vaccine Clinic Registration Form

* Please fill out the required details below
Section I. Personal Information
Arrived For
Date #1

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date # 2

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Vaccine
Patient's Full Name:

First NameMlLast Name
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Age:
Phone Number:
Email:
Gender:
Ethnicity:
Race:

Other
Address:

Street Address Line 2

STATE
Primary Care Doctor
Doctor City/State:
Are you one of the following?

Other
Name of Employer
What dose of COVID-19 vaccine will this be?
When did you receive your first dose?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
[FOR SECOND DOSE ONLY] I consent to receive the second dose and I verify that I have not tested positive for COVID-19 for the past 90 days and my medical conditions have not changed
Section II. Questionnaire for Immunization

Please select the correct option below:

Rows	Yes	No	Don't know or N/A
COVID-19 Screening Questions: In the past two weeks, have you tested positive for COVID-19 or are you currently being monitored for COVID-19?
In the past two weeks, have you had a known exposure with anyone who tested positive for COVID-19?
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?
Questionnaire for Immunization: Do you feel sick today?
Do you have an allergy to medications, foods, or any vaccines (eggs, gelatin, thimerosal, neomycin, gentamicin, latex, aluminum, preservatives, baker's yeast, etc.)?
Do you carry an EpiPen?
Have you received COVID-19 monoclonal antibodies or convalescent plasma in the last 90 days?
Have you ever had a serious reaction or fainted after receiving any vaccination?
Have you ever had a seizure, brain disorder, or Guillain-Barre Syndrome?
For women: Are you pregnant or are you planning on becoming pregnant during the next month?

Please specify the allergy from Q2:
Section III. Appointment Scheduler
**Vaccine supply is limited. Please keep your appointment or call if you need to cancel or change it. Additionally, due to vaccine requirements; we may call you to see if you can come earlier, later or to a nearby location. If you miss an appointment, no doses will be held to guarantee your dose.**
Please pick a day and time for your vaccination
Section IV. Signatures

I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) - COVID-19 Fact Sheet, 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, a minor for whom I represent that I am authorized to sign this Consent and Release.
CLICK HERE TO LEARN WHAT YOU NEED TO KNOW ABOUT THE VACCINE
Signature of Person to Receive Vaccine & EUA/VIS (or Signature of Parent/Guardian if Patient is < 18 yo)
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 and Consent for Vaccination:
Please take or upload a picture of your State ID card or Drivers License

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Drivers License # or Social Security #
Do you have Medical Insurance?
I attest that I am currently un-insured. (HRSA will cover this if you are Uninsured, at no cost) Misrepresentation of insurance status could result in patient responsibility
Please take or upload a picture of your Insurance Card (Optional)

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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.
INSURANCE Name
Insurance Subscriber / Member ID
Policy Number
Group Number
Should be Empty:

COVID Vaccine Clinic Registration Form