Pfizer COVID Vaccine Consent Form

Pfizer COVID-19 Vaccine Consent Form and Screening Questionnaire

Palmyra Community Vaccine Clinic
Section I. Personal Information
Patient's name*

First nameLast Name
Date of Birth:*

MonthDayYear
Phone Number:*
Email:*
Ethnicity:*

Hispanic or LatinoNot HispanicPrefer not to specify
Gender:*

MaleFemaleUnknownNon-Binary
Race:*

WhiteAsianAmerican Indian OR Alaska NativeNative Hawaiian or Other Pacific IslanderPrefer not to specifyBlack or African-AmericanOther Race
Address:*

Street Addres

Street Address Line 2

CityState

Postal / Zip Code
Please specify chronic condition:
https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html?utm_medium=email&utm_source=govdelivery
Section II. Questionnaire for Immunization

Please select the correct option below:*

	Yes	No	Don't know or N/A
COVID-19 Screening Questions: In the past two weeks, have you tested positive for COVID-19 or are you currently being monitored for COVID-19?
In the past two weeks, have you had a known exposure with anyone who tested positive for COVID-19?
Have you had a new onset of fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, nausea, vomiting, or diarrhea?
Questionnaire for Immunization: Do you feel sick today?
Do you have an allergy to medications, foods, or any vaccines (eggs, gelatin, thimerosal, neomycin, gentamicin, latex, aluminum, preservatives, baker's yeast, etc.)?
Do you carry an EpiPen?
Have you been diagnosed with or suspected of having covid in the last 90 days?
If yes to the above question, did you receive medications, plasma or other treatment?
Have you ever had a serious reaction or fainted after receiving any vaccination?
Have you ever had a seizure, brain disorder, or Guillain-Barre Syndrome?
Have you received any other immunizations in the last 14 days?
Do you have a bleeding disorder or are you taking a blood thinner?
Do you have a history of or a risk factor for a blood clotting disorder?
Do you have dermal fillers?
Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
For women: Are you pregnant or are you planning on becoming pregnant during the next month?

Please specify the allergy from Q2:
Section III. Appointment Scheduler
Please pick a date and time for your First dose*
Please pick a date and time for your Second dose(3 weeks apart)*
Section IV. Signatures

I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) (https://www.cdc.gov/vaccines/covid-19/eua/index.html), 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. I understand the benefits and risks of the vaccine(s). I consent to, or give consent for, the administration of the vaccine(s) and the notification of my primary care physician. I fully release and discharge their offices, directors and employees from any liability for illness, injury, loss or damage which may result there from. I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment. I understand that I should remain in the pharmacy area or instructed location for 15 minutes for observation in case there is an adverse reaction 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 and Release.
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 Person (authorized Parent/Guardian) to Receive Vaccine & EUA/VIS*

Clear
Primary insurance company *
Insurance Member ID #*
Insurance group number*
Medicare ID #*
Please upload pictures of front & back of medical insurance card ( If no ins. Please upload ID card)*

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(Vaccine is free, Vaccine administration cost is fully covered by insurance) Cancelof
Please upload valid picture ID for identification purpose*

Browse Files

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Authorization*

I authorize the pharmacy to bill my insurance on my behalf for the vaccine administration and the information provided is true and accurate.I do not have any insurance, including but not limited to Medicare, Medicaid or any other private or government-funded health benefit plan
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.

Once you click submit, you will be redirected to fill out the form for your 2nd Dose of COVID-19 Vaccine. Please select the date 3 weeks apart from your 1st dose appointment.
Vaccine Administration (Pharmacist Use ONLY)

I hereby certify that I have verified the screening questionnaire and consent with the above named patient

Vaccine: COVID-19 Vaccine Dose: 0.3ml Lot Number: EW0202 Expire Date: 09/21 Manufacture: Pfizer

Injection Site: Left Arm / Right Arm Route: IM

VIS Identification: EUA COVID-19 VACCINE Date of Publication: 05/10/21

Did an Adverse Reaction occur? Yes No

Contacted VAERS 800-822-7967 Date/Time:

Primary Care Physician contacted: Yes No

Administered By: Pharmacist Signature:
Should be Empty:

Pfizer COVID-19 Vaccine Consent Form and Screening Questionnaire