• Format: (000) 000-0000.
  • Date of Birth
     / /
    2 digit month, 2 digit day, 4 digit year

  • 1) MEDICAL HISTORY: Complete the following questions for the individual receiving the vaccine. (If you answer "YES" to any of the following, you may not be elligible for the COVID-19 vaccine)

  • If Yes and further guidance is needed, please refer to the Pfizer website at www.PfizerMedInfo.com or call 1-800-438-1985 for the following vaccine information: vaccine temperature, excursions, efficacy, safety, stability, dosage, vaccine ingredients, mechanism of action and administration. For an overview for Vaccination Providers about Moderna COVID-19 vaccine refer to www.modernatx.com or call 1-866-MODERNA

  • Have you had a previous COVID-19 vaccine?
  • Have you had any vaccines within the previous 14 days? (Pfizer-BioNTech or Moderna COVID-19 vaccine should be administered alone with minimal interval of 14 days before or after any other vaccine)
  • Are you feeling sick or have fever today? Do you have COVID-19 infection or are you currently in quarantine for known exposure?
  • Have you ever had a severe allergic reaction to any vaccine, vaccine component, or injectable therapy? (Including Pfizer-BioNTech or Moderna COVID-19 vaccine) Such as difficulty breathing, swelling of your face and throat, fast heartbeat, dizziness and/or weakness, or bad rash?
  • Are you breastfeeding, pregnant, or plan to become pregnant? Women in this group may want to discuss with their physician before receiving Pfizer BioNTech or Moderna COVID-19 vaccine to help make an informed decision.
  • Are you immunocompromised or have any of the following issues: HIV, cancer, chronic kidney disease, heart disease, sickle cell, severe obesity, or diabetes mellitus? Do you use tobacco products? Are you receiving any immunosuppressive therapy? If so, you may still be eligible to receive the Pfizer BioNTech or Moderna COVID-19 vaccine unless otherwise contraindicated.
  • Have you received Monoclonal antibodies or convalescent plasma as part of COVID-19 treatment?Pfizer BioNTech or Moderna COVID-19 vaccine should be deferred for at least 90 days to avoid interference of treatment with vaccine-induced immune response.

  • Note: Depending on vaccine type, a second dose of COVID-19 vaccine may be due in 21 days or 28 days after the initial vaccine. Refer to your COVID-19 vaccination record card for your second dose due date. Contact your PCP or your ADH Local Health Unit in 21 days or 28 days for more information. Keep your COVID-19 vaccination record card for your records for proof of initial vaccine date.

  • 2) RELEASE AND ASSIGNMENT.

    Please read the section on the reverse side of this form. The Provider's Privacy Notice is available at the clinic. Then sign in the box at the right.

  • My signature below indicates that I have read, understand, and agree to section 2. Release and Assignment of the COVID-19 Immunization Consent Form and Vaccine Recipient Emergency Use of Authorization Fact Sheet (EUA) and received a copy of the Provider's Privacy Note. 

  • Clear
  • DATE
     / /
    2 digit month, 2 digit day, 4 digit year

  • RELEASE AND ASSIGNMENT: 

    • I have read or had explained to me the Vaccine Recipient Emergency Use Authorization (EUA) Fact Sheet for COVID-19 vaccine risks and benefits. To read the Vaccine Recipient Emergency Use Authorization for Moderna COVID-19 vaccine visit the website https://www.fda.gov/media/144638/download or (modernatx.com) you may also visit the Local Health Unit or private provider to receive a printed copy of the EUA Fact Sheet. 
    • I give consent to this COVID-19 provider/staff for the individual names below to be vaccinated with the COVID-19 vaccine.
    • I hereby acknowledge that I have reviewed a copy of the Provider's Privacy Notice.
    • I understand that information about this COVID-19 vaccination will be included in (WeblZ) Arkansas Immunization Information System.

    To My Insurance Carrier(s):

    • I authorize the release of any medical information necessary to process my insurance claim(s).
    • I authorize and request payment of medical benefits directly to this COVID-19 Provider.
    • I agree that the authorization will cover all medical services rendered until I revoke the authorization.
    • I agree that the photocopy of this form may be used instead of the original.

  • PATIENT INFORMATION: 

  • Gender
  • Race
  • Insurance Status (Check Appropriate Box):
  • Patient's Relationship to Insurance Policy Holder:

  • REQUIRED POLICY HOLDER INFORMATION:

  • Policy Holder Date of Birth
     / /
    2 digit month, 2 digit day, 4 digit year
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