Vaccination Consent Form

Name

First NameLast Name

Date of Birth

Date

Age

Gender

Phone Number

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Ethnicity

Race

Primary Care Doctor

Doctor City/State

Street Address

Street Address Line 2

CityState / Province

Mother's Maiden Name

Emergency Contact Name

Relationship to Emergency Contact

Emergency Contact Phone Number

Area CodePhone Number

Which BIVALENT COVID-19 vaccine would you like to receive?

When did you receive your last vaccine?

Date

Rows	Yes	No
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?
Have you ever had an allergic reaction* to polysorbate, which is found in some vaccines, film coated tablets, and intravenous steroids?
Have you ever had an allergic reaction* to another vaccine (other than COVID-19 vaccine) or an injectable medication?
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, venom, environmental, or oral medication allergies.
Have you ever had an allergic reaction* to a vaccine or injectable therapy that contains multiple components, one of which is a COVID-19 vaccine component, but is not known which component elected the immediate reaction?
Have you ever had an allergic reaction* to a previous dose of COVID-19 vaccine?
Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?
Do you carry an EpiPen®?
Do you have a bleeding disorder or are you taking a blood thinner?
Do you have dermal fillers?

Rows	Yes	No
Do you have allergies to medications, food (eggs), a vaccine component, or latex? Do you carry an epipen?
Have you ever had a serious reaction after receiving a vaccination?
Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g., diabetes), anemia, or other blood disorder?
Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
Have you ever had a seizure, brain disorder, or Guillain-Barre Syndrome?
In the past 3 months, have you taken medications that weaken your immune system, such as cortisone, prednisone, other steroids, or anticancer drugs, or have you had radiation treatments?
During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?
Do you feel sick today?
In the past two weeks, have you had a known exposure with anyone who tested positive for COVID-19?
Have you ever had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?
Are you currently taking any antiviral medications for influenza or COVID-19?
Have you received any other vaccinations in the past 14 days?
For women: Are you pregnant or breastfeeding, or are you planning to become pregnant in the next month?

*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.

I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA), 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 and for whom I am authorized to sign this Consent and Release.

Signature of Person to Receive Vaccine & EUA, or Parent/Guardian, if Recipient is a Minor

Signature of Acknowledgement of Vaccine Information Statement

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 Acknowledgement of Notice of Privacy Practices

Please indicate type of insurance

Medicaid Provider

Policy/Member ID

Medicaid #

Medicaid Group #

Medicare Subscriber ID

Responsible Party

Policy Holder's Date of Birth

Date

Insurance Provider

Subscriber ID

Bin #

PCN

Group #

In order to have your vaccine administration fee paid for by the United States Health Resources & Services Administration’s COVID-19 Program for uninsured patients, please select to provide one of the following:

State identification number and state of issuance

Driver's license number and state of issuance

Social Security Number

If you are vaccinating a child (an individual under the age of 18 years old) as per state mandates. Please include the following... Name of Parent filling out paperwork and your license number including the state of issuance.

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.

Name of Vaccine

COVID-19 Vaccine Manufacturer

Other

Time Removed from -80 C

:HourMinutesAM/PM Option

Date Removed

Date

Vaccine Lot Number

Expiration Date

Date

Dosage

Injection Site

Other

Patient Temperature

Signature of Pharmacist who Administered Vaccine

Pharmacist Name

First NameLast Name

Date Administered

Date

Time Administered

:HourMinutesAM/PM Option

Vaccination Consent Form

Personal Information

Immunization Questionnaire

Signatures

Insurance

For Pharmacy Use Only