Moderna 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.
Please select your appropriate phase of the vaccine rollout based on CDC and North Carolina DHHS Guidelines linked above.
*
Please Select
1a Health Care Worker
1a Long Term Care Resident
1b Ages 65 and older
1b Ages 18 and older with one or more chronic medical condition(s)
1c Ages 50 to 64
1c School or Licensed Childcare Personnel
Other
Appointment
Vaccine Recipient Name
*
First Name
Middle Name
Last Name
Vaccine Recipient Physical Address
*
Street Address
Street Address Line 2
City
State Initials
Postal / Zip Code
Date of Birth
*
/
Month
/
Day
Year
Patients must be 18 years old to receive the vaccine
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 Islander
White
Ethnicity
*
Please Select
Hispanic or Latino
Not Hispanic or Latino
Unknown
Vaccine Recipient Phone Number
*
Format: (000) 000-0000.
Please Enter Your Email
*
Required for proper vaccine documentation
Mother's Maiden Name
*
Required for proper vaccine documentation
Primary Care Provider Name
Emergency Contact Name
Relationship to Emergency Contact
*
Phone Number of Emergency Contact
Format: (000) 000-0000.
COVID-19 Vaccine Screen Questions
*
Rows
Yes
No
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
Polysorbate?
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?
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.
6. Have you received any vaccine in the last 14 days?
7. Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19?
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?
COVID-19 Vaccine Manufacturer for the first dose received (do not complete if you selected "no" to #2 above.)
Please Select
Moderna
Pfizer
Janssen
Required if you selected "Yes" to #2. We are getting Pfizer doses only. So, if you've had Moderna as your first dose, please stop here as you do not qualify for Pfizer as a second dose.
Date of first dose (do not complete if you selected "no" to #2 above.)
/
Month
/
Day
Year
Required if you selected "Yes" to #2
Date of second dose (do not complete if you selected "no" to #2 above.)
/
Month
/
Day
Year
Required if you selected "Yes" to #2
Consent (check each box below after reading and prior to signing the form)
*
Rows
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.
*
I have health insurance.
I do not have health insurance.
Please enter your Insurance Member ID
Please enter your Insurance RxBIN
Please enter your Insurance RxPCN
Please enter your Insurance RxGrp
Please provide a picture of the front of your insurance card.
Please provide a picture of the back of your insurance card.
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 (ID) and state of issuance
Driver's license (DL) number and state of issuance
Please enter the last 4 digits of your social security number:
If no social, enter zeros
Please enter your state ID or DL number:
If no ID, enter zeros
Please enter the state of issuance of your ID or DL.
E.g. TX (If no ID or Driver License, enter NA)
Please provide a picture of the front of your state issued ID or DL.
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):
*
Date Signed
*
/
Month
/
Day
Year
Date
Preview PDF
Print Form
Submit Consent Form (required)
Should be Empty: