COVID-19 Vaccine Screening Form

Are you 5 years of age and older?*

YesNo

Select an appointment time for the COVID-19 Vaccine. If less than 18 years of age, parent/legal guardian should be present with ID)*

Vaccine Recipient Name*

First NameMiddle NameLast Name

Vaccine Recipient Physical Address*

Street Address

Apt #

CityState Initials

Zip Code

Date of Birth*

Gender at Birth*

Race*

Ethnicity*

Phone Number*

Email*

example@example.com

Emergency Contact Name

Relationship to Emergency Contact

Phone Number of Emergency Contact*

COVID-19 Vaccine Screen Questions*

	Yes	No
1. Are you feeling sick today?
2. In the last 10 days, have you had a COVID-19 Test because you had symptoms and are still awaiting your test results or been told by a healthcare provider or health department to isolate or quarantine at home due to COVID-19 infection, exposure, or travel?
3. Have you been treated with antibody therapy or convalescent plasma for COVID-19 in the past 90 days (3 months)?
4. 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
5. Have you received any vaccine in the last 14 days ?
6. Are you pregnant or considering becoming pregnant or breastfeeding?
7. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
8. Do you take any medications that affect your immune system, such as cortisone, prednisone, or other steroids, anticancer drugs, or have you had any radiation treatments?
9. Do you have a bleeding disorder or are you taking a blood thinner?

Which arm would you like to get the injection on*

Left ArmRight Arm

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 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.*

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.

WHICH COVID-19 VACCINE WOULD YOU LIKE?

Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):*

Date Signed

Date

Pharmacist Name

First and Last Name

Pharmacist Signature

Immunizer Name

First and Last Name

Immunizer Signature

Vaccine Manufacturer

Moderna

Lot Number

Expiration Date:

Pharmacy Name

Pharmacy CLIA Number: *

COVID-19 VACCINE CONSENT FORM