Appointment
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COVID-19 Vaccine Consent Form
In order to receive the vaccine, you must be in the most appropriate phase of the vaccine rollout. Visit this link (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations.html) for more information at the federal level. States may have a different approach.
All Florida residents are now eligible to receive any COVID-19 vaccine as prescribed by the Food and Drug Administration. The Moderna and Pfizer vaccines are authorized for persons age 6 months and up. Do you qualify to receive the COVID-19 Vaccine as per FL State rules?
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Yes
No (Fill out the form and join our waitlist/standby) We will call contact you if available.
Vaccine Recipient Name
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First Name
Middle Name
Last Name
Vaccine Recipient Physical Address
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Street Address
Apt #
City
State Initials
Zip Code
Date of Birth
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Month
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Day
Year
Gender at birth
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Please Select
Male
Female
Race
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Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Ethnicity
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Please Select
Hispanic or Latino
Not Hispanic or Latino
Unknown
Vaccine Recipient Phone Number
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Mother's Maiden Name
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Required for proper vaccine documentation
Primary Care Provider Name
Emergency Contact Name
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Relationship to Emergency Contact
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Please Select
Brother
Sister
Sibling
Mother
Parent
Father
Guardian
Spouse
Grandparent
Child
Foster child
Stepchild
Care Giver
Other
Phone Number of Emergency Contact
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Email
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example@example.com
Please select your vaccine:
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Moderna/Spikevax (age 12+)
Is this the patient’s first, second or third dose of the COVID-19 vaccination?
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Booster
COVID-19 Vaccine Screen Questions
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Yes
No
1. Do you have today or have you had at any time in the last 10 days a fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea, vomiting, or diarrhea?
2. Have you tested positive for and/or been diagnosed with COVID-19 infection within the last 10 days?
3. Have you had a severe allergic reaction (e.g. needed epinephrine or hospital care) to a previous dose of this vaccine or to any of the ingredients of this vaccine?
4.
Have you had any
other vaccinations in the last 14 days (e.g. influenza vaccine, etc.)?
5. Have you had any COVID-19 Antibody therapy within the last 90 days (e.g. Regeneron, Bamlanivimab, COVID Convalescent Plasma, etc.)
6. Do you carry an Epi-pen for emergency treatment of anaphylaxis and/or have allergies or reactions to any medications, foods, vaccines or latex?
7. For women, are you pregnant or is there a chance you could become pregnant?
8. For women, are you currently breastfeeding?
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 a female age 18 to 49 years old receiving the Janssen (Johnson & Johnson) COVID-19 vaccine?
12. If you are under the age of 18, are you and/or your guardian aware that you are only eligible to receive the Pfizer vaccine?
13. Have you received a previous dose of covid-19 vaccine?
If Yes, which manufacturer's vaccine did you receive:
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Which arm would you like to get the injection on
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Left Arm
Right Arm
Consent (check each box below after reading and prior to signing the form)
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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 Moderna 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.
The vaccine is available to anyone no matter if insured or uninsured. Please check only one of the following.
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If INSURED, check this box attesting to bringing in your prescription and medical insurance cards for your vaccine appointment. By selecting this, you are also authorizing the pharmacy to bill your insurance on your behalf for the immunization – understanding you will not incur any costs.
If UNINSURED, you must check this box to attest that the the following information is true and accurate: I do not have any insurance, including but not limited to, Medicare, Medicaid, or any other private or government-funded benefit plan.
Please Upload Insurance Card
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Browse Files
Drag and drop files here
Choose a file
Cancel
of
For uninsured patients, please select at least one of the following that you will bring with you to your appointment.
State identification number and state of issuance
Driver's license number and state of issuance
Please Upload Supporting Uninsured Document
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):
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Date Signed
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Month
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Day
Year
Date
Pharmacist Name
First and Last Name
Pharmacist Signature
Immunizer Name
First and Last Name
Immunizer Signature
Lot Number
Expiration Date:
Vaccine Manufacturer
Moderna/Spikevax Vaccine
Pfizer Vaccine
Pharmacy Name
Pharmacy NPI
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Submit
Should be Empty: