Please select your appropriate phase of the vaccine rollout based on CDC or Texas DSHS Guidelines linked above.*

We are so sorry! You are not eligible for the COVID-19 vaccine at this time. Please check with CDC and Texas DSHS to see when your appropriate phase is eligible for the COVID-19 Vaccine.

Vaccine Recipient Name*

First Name Middle Name Last Name

Vaccine Recipient Physical Address*

Street Address

Street Address Line 2

City State Initials

Postal / Zip Code

Date of Birth*

Gender at birth*

Race*

Ethnicity*

Vaccine Recipient Phone Number*

Please Enter Your Email*

Required for proper vaccine documentation

Mother's Maiden Name*

Required for proper vaccine documentation

Primary Care Provider Name

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. Have you ever received a dose of COVID-19 Vaccine?
3a. Have you ever had an allergic reaction to acomponent of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures?
3b. Have you ever had an allergic reaction toPolysorbate?
3c. Have you ever had an allergic reaction to a previous dose of COVID-19 Vaccine?
4. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?
5. 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.
6. Have you received any vaccine in the last 14 days?
7. Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19?
8. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? [note: monoclonal antibodies does not include antibiotics that you would be prescribed and filled at a pharmacy]
9. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
10. Do you have a bleeding disorder or are you taking a blood thinner?
11. Are you pregnant or breastfeeding?

COVID-19 Vaccine Manufacturer for the first dose received (do not complete if you selected "no" to #2 above.)

Required if you selected "Yes" to #2. We are getting Pfizer doses only. So, if you've had Moderna as your first dose, please stop here as you do not qualify for Pfizer as a second dose.

Date of first dose (do not complete if you selected "no" to #2 above.)

Required if you selected "Yes" to #2

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.*

I have health insurance. I do not have health insurance.

Please enter your Insurance Member ID

Please enter your Insurance RxBIN

Please enter your Insurance RxPCN

Please enter your Insurance RxGrp

Please provide a picture of the front of your insurance card.

Please provide a picture of the back of your insurance card.

For uninsured patients, please select at least one of the following that you will bring with you to your appointment.*

Social Security Number State identification number (ID) and state of issuance Driver's license (DL) number and state of issuance

Please enter the last 4 digits of your social security number:

Please enter your state ID or DL number:

Please enter the state of issuance of your ID or DL.

E.g. TX

Please provide a picture of the front of your state issued ID or DL.

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

Clear

Date Signed*

Date

Appointment

Please click the [Preview PDF] button below to print your form and bring to your appointment on Sunday, March 28th.

COVID-19 Vaccine Consent Form