2521 13th St. Suite A Saint Cloud, FL 34769
Follow signs for Drive-Thru behind the building to receive the vaccine
COVID-19 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 (12 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 16 and over.
Is patient to be vaccinated 12 years or older?
Johnson & Johnson vaccine is approved for individuals 18 years old and above. Pfizer vaccine is approved for individuals 12 years old and above.
Which vaccine would you prefer? (Subject to availability)
Johnson & Johnson (Janssen)
Vaccine Recipient Name
Where do you want your vaccine?
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 Line 2
Postal / Zip Code
Date of Birth
Gender at birth
American Indian or Alaska Native
Black or African American
Native Hawaiian or Other Pacific
Hispanic or Latino
Not Hispanic or Latino
Vaccine Recipient Phone Number
Do you have insurance?
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
1. Are you feeling sick today?
2. Have you ever received a dose of COVID-19 Vaccine?
3a. Have you ever had an allergic reaction to a
component of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures?
3b. Have you ever had an allergic reaction to
3c. Have you ever had an allergic reaction to a previous dose of COVID-19 Vaccine?
4. 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.]
5. 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.
7. Have you had a POSITIVE test for COVID-19 in the previous 10 days?
8. 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]
9. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
10. Do you have a bleeding disorder or are you taking a blood thinner?
11. Are you pregnant or breastfeeding?
12. Are you a female age 18 to 49 years old receiving the Janssen (Johnson and Johnson) COVID-19 vaccine?
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 understand that at this time, the COVID-19 vaccine requires 2 doses given 21-28 days apart depending on the manufacturer. If this is my second dose, I will bring my vaccine card with me to be completed.
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.
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):
Submit Consent Form (required)
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