COVID-19 Vaccine Intake Consent Form

COVID-19 Vaccine Intake Consent Form
Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of Clinic
Phone Number of Clinic
Please enter a valid phone number.Format: (000) 000-0000.
Address of Clinic
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Patient Information
Name of Patient
First NameLast Name
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Gender
Is patient above 65 years old or Medicare Eligible?
Is patient insured?
Please check the item below for attestation that the above-named patient is not insured and provide any of the following: SSN, State ID Number, Driver's License Number
State ID Number
Driver's License ID Number
For Medicare Eligible Patients
Medicare Part A/B ID Number (MBI)
Card ID Number
Group ID Number
Payer ID Number
Health Card / Insurance Card Holder
Name of Prescription Insurance
Card ID Number
Group Number
BIN
PCN
Dose Count:
Medical Screening Evaluation
Are you feeling sick or currently sick?
Have you ever had a severe allergic reaction to any medication in the past, including, but not limited to vaccines, antibiotics, antibacterial drugs, etc.?
Have you received any vaccination in the past 14 days?
Have you received a COVID-19 vaccine before?
Please indicate the COVID-19 vaccine brand/product
Have you received a COVID-19 treatment in the past 90 days?
Are you pregnant or currently breastfeeding?
Are you taking blood thinners or you have a bleeding disorder?
Consent and Acknowledgment
A copy of a Vaccine Information Sheet or a fact sheet has been provided to me corresponding to the vaccine that I will receive. I have read the information and I have had the opportunity to ask questions and by which answers were given to me to my satisfaction. I understand that the vaccine has corresponding benefits and risks and I assume full responsibility for its effect or reaction to my body.
I request that the vaccine be given to me or to the above-named patient for whom I am authorized. I have been advised and I understand that I have to remain within the premises for 15 minutes after I have been administered the vaccine.
I understand that in case side effects start to manifest, I shall call my doctor, the pharmacy, and/or 911.

I understand that my health information may be required to be disclosed to the physician responsible for this protocol of gathering information of people vaccinated (if applicable) for the benefit or use of my insurance plan, health services, medical facilities, my physician, federal registries, for the purpose of this and other procedures or treatment. I also understand that this disclosure shall be limited to as previously stated and shall not be used for other purposes not authorized by me.
Representation
Signature of Patient
Clear
Date Signed
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of Legal Guardian/Representative
First NameLast Name
Signature of Legal Guardian/Representative
Clear
Date Signed by Legal Guardian/Representative
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
For Immunizer
Date Administered
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Manufacturer
Vaccine Name
Volume (ml)
Lot Number
Route
Site
VIS date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Exp. Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Temperature of Patient
Ferenheit
Name of Administering Immunizer
PrefixFirst NameLast Name
Signature
Clear
Should be Empty:

COVID-19 Vaccine Intake Consent Form

Patient Information

Medical Screening Evaluation

Consent and Acknowledgment

For Immunizer