2521 13th St. Suite A Saint Cloud, FL 34769
Follow signs for Drive-Thru behind the building to receive the vaccine
COVID-19 and Flu Vaccine Consent Form
In order to receive the vaccine, you MUST be in the most appropriate phase of the vaccine rollout per Osceola-DOH guidelines (5 years and up).Visit this link (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations.html) for more information at the federal level. Other states may have a different eligibility.
NOTE: You MUST complete this form prior to vaccination. Thank you for your patience.
Per State of Florida and CDC guidelines, to qualify you MUST be 5 and over.
Is patient to be vaccinated 5 years or older?
*
Please Select
Yes
No
Johnson & Johnson and Moderna vaccine is approved for individuals 18 years old and above. Pfizer vaccine is approved for individuals 5 years old and above.
Which COVID-19 Dose are you receiving
Please Select
First
Second
Bivalent Booster
1st Booster is approved 5 months after 2nd dose Pfizer or Moderna and 2 months after Janssen. Pfizer boosters approved ages 12 and up, Moderna and Janssen 18 and up. Single Booster of Bivalent must be at least 2 months from primary series and 12 years of age and older.
Which vaccine would you prefer? (Subject to availability)
Please Select
No Preference
Bivalent Pfizer - 12 and up
Bivalen Pfizer - 5 - 11 y/o
Bivalent Moderna - 18 and up (currently unavaialble)
Pfizer - 12 and up
Pfizer - 5-11 y/o vaccine
Novavax
Janssen (Johnson & Johnson)
VACCINE AVAILABILTY HAS CHANGED TO TUESDAYS AND FRIDAYS ONLY (SUBJET TO CHANGE)
Vaccine Recipient Name
*
First Name
Middle Name
Last Name
Where do you want your vaccine?
*
Please Select
Pharmacy Drive-Thru
Homebound Patient (not currently available)
If you select Drive-Thru, you must schedule an appointment date and time below.
Drive Through Appointment Time
*
Person Completing form (if not patient)
Name, Contact #, Company (Provider, HHA, etc)
Vaccine Recipient Physical Address
*
Street Address
Street Address Line 2
City
State Initials
Postal / Zip Code
Date of Birth
*
/
Month
/
Day
Year
Gender at birth
*
Please Select
Male
Female
Race
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific
White
Ethnicity
*
Please Select
Hispanic or Latino
Not Hispanic or Latino
Unknown
Vaccine Recipient Phone Number
*
Email
example@example.com
Do you have insurance?
*
Yes
No
Insurance Company Name
Medicare # (Red, White and Blue Card), Insurance ID# or Social Security #
*
Required for proper vaccine documentation
Emergency Contact Name
*
Relationship to Emergency Contact
*
Phone Number of Emergency Contact
*
COVID-19 Vaccine Screen Questions
*
Yes
No
1. Are you feeling sick today?
2. Have you ever had an allergic reaction to a
component of the COVID-19 vaccine, including polyethylene glycol (PEG) or polysorbate, which is found in some medications, such as laxatives and preparations for colonoscopy procedures?
3. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?
[Allergic Reaction Defined: This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.]
4. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a component of COVID-19 vaccine, polysorbate, or any vaccine or injectable medication?
This would include food, pet, environmental, or oral medication allergies.
5. Have you had a POSITIVE test for COVID-19 in the previous 10 days?
6. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?
[note: monoclonal antibodies does not include antibiotics that you would be prescribed and filled at a pharmacy]
7. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
8. Do you have a bleeding disorder or are you taking a blood thinner?
9. Are you pregnant or breastfeeding?
For Booster selected above, do you attest that you qualify for COVID-19 booster in accordance with current CDC/ACIP guidelines?
Consent (check each box below after reading and prior to signing the form)
*
Check each box
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet (the Pfizer Fact Sheet is available after clicking submit), a copy of which I was provided with this Consent Form. 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 Form.
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.
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
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):
Clear
Date Signed
*
/
Month
/
Day
Year
Date
Submit Consent Form (required)
Should be Empty: