VaxOn Vaccine Consent Form

Vaccine consent form

Clinic Location:

875 Walnut St Suite 275-17, Cary, NC 27511

Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Gender
Race
Ethnicity
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
I authorize VaxOn to text me or leave a detailed message regarding my visit today on the voicemail of the telephone number I have provided.

Please answer all the following Questions:

Rows	Yes	No
COVID-19 Screening Questions: 1- In the past two weeks, have you tested positive for COVID-19 or are you currently being monitored for COVID-19?
2- In the past two weeks, have you had a known exposure with anyone who tested positive for COVID-19?
3- 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: 4- Do you feel sick today?
5- Do you have an allergy to medications, foods, or any vaccines (eggs, gelatin, thimerosal, neomycin, gentamicin, latex, aluminum, preservatives, baker's yeast, etc.)? ...................................
6- Have you received any vaccinations in the past 14 days?
7- Have you received COVID-19 monoclonal antibodies or convalescent plasma in the last 90 days?
8- Have you ever had a serious reaction or fainted after receiving any vaccination?
9- Have you ever had a seizure, brain disorder, or Guillain-Barre Syndrome?
10- Do you have any chronic health condition such as Cancer, Chronic Kidney Disease, Immunocompromised, Chronic Lung Disease, Obesity, Sickle Cell Disease, Diabetes, Heart Disease, Other? .................................................
For women:11- Are you pregnant or are you planning on becoming pregnant during the next month?

Do you have health insurance, Medicare, Medicaid or any commercial or government-funded health benefit plan?
Select insurance company, or Medicare or Medicaid plan
Member number / ID number
Group number (Optional)
Please upload your insurance Card

Provide an image of your insurance card to help avoid errors in billing your insurance company.
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Please provide a valid driver’s license/state ID number, which is used for the HHS Uninsured Program administration. You may continue to book an appointment if you do not have or prefer not to provide this information.
Driver’s license / state ID number
State
Please upload your Driver's License or state ID Card

Cancelof

Vaccine consent form