Pre-Vaccination Checklist for COVID-19 Vaccines
The following questions will help us determine if there is any reason you should not get the COVID-19 vaccine today. If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions may be asked. If a question is not clear, please ask your healthcare provider to explain it.
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Cell phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Weight (in pounds)
*
Are you feeling sick today?
*
Yes
No
Don't know
Have you ever received a dose of COVID-19 vaccine?
*
Yes
No
Don't know
When did you receive the previous dose of COVID-19 vaccine?
*
-
Month
-
Day
Year
Date
Which formulation of COVID-19 vaccine did you receive in the past?
*
Moderna
Pfizer
Have you ever had a severe allergic reaction (e.g. anaphylaxis) to something? For example, a reaction for which you were treated with epinephrine or EpiPen, or for which you had to got to the hospital?
*
Yes
No
Don't know
Was the severe allergic reaction after receiving a COVID-19 vaccine?
*
Yes
No
Don't know
Was the severe allergic reaction after receiving another vaccine or another injectable medication?
*
Yes
No
Don't know
Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?
*
Yes
No
Don't know
Have you received another vaccine in the last 14 days?
*
Yes
No
Don't know
Have you had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?
*
Yes
No
Don't know
Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
*
Yes
No
Don't know
Do you have a bleeding disorder or are you taking a blood thinner?
*
Yes
No
Don't know
Are you pregnant or breastfeeding?
*
Yes
No
Don't know
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Social Media Photo Release Form
Can we use your name?
*
First name
Nickname
Anonymous
Decline use altogether
Please indicate your consent to the following (select all that apply)
I authorize and grant the COVID-19 care team, and their associates, permission to take my photos regarding my experiences with them.
I grant the COVID-19 care team, and their associates, permission to use my photos on Facebook, Twitter, Instagram, and other social media platform.
I allow the COVID-19 care team, and their associates, permission to edit, alter, copy, or distribute the photos for social media advertising and marketing.
I agree that the photos belong to the COVID-19 care team, and their associates.
I understand that I will not receive any monetary compensation.
Signature
Consent
I certify that I am: (a) the patient and at least 18 years of age; (b) the parent or legal guardian of the patient and confirm that the patient is at least 16 years of age; or (c) authorized to consent for vaccination for the patient named above. Further, I hereby give my consent to Family Matters DPC or its associates to administer the COVID-19 vaccine.
I understand that this product has not been approved or licensed by FDA, but has been authorized for emergency use by FDA, under an EUA to prevent Coronavirus Disease 2019 (COVID-19) for use in individuals 18 years of age and older; and the emergency use of this product is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of the medical product under Section 564(b)(1) of the FD&C Act unless the declaration is terminated or authorization revoked sooner.
I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccine(s). I understand the risks and benefits associated with the above vaccine and have received, read and/or had explained to me the Emergency Use Authorization Fact Sheet on the COVID-19 vaccine I have elected to receive. I also acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction.
I acknowledge that I have been advised to remain near the vaccination location for approximately 15 minutes after administration for observation; and for 30 minutes if I have a history of anaphylaxis from any cause. If I experience a severe reaction, I will call 9-1-1 or go to the nearest hospital.
On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless Family Matters DPC, and their staff, associates, successors, divisions, affiliates, subsidiaries, officers, directors, contractors and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the vaccine listed above.
I acknowledge that: (a) I understand the purposes/benefits of PA-SIIS, Pennsylvania's immunization registry and (b) will include my personal immunization information in PA-SIIS and my personal immunization information will be shared with the Centers for Disease Control (CDC) or other federal agencies.
I acknowledge receipt of the Notice of Privacy Rights.
By signing, I have completed this form to the best of my knowledge and consent to the agreement as written and receipt of vaccine.
Signature of Patient or Authorized Representative
*
Print Name (if someone other than patient to receive vaccine)
First Name
Last Name
Submit
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