COVID Immunization Consent Form

COVID Immunization Consent Form
Immunization clinic site
Name (as it appears on insurance card)*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Age:*
Social Security Number:*
Gender:*

MaleFemale
Address*

Email Address (Please contact me about screenings, immunization clinics and other promotions.)

Street Address

CityState / Province

Postal / Zip Code
Phone Number:*
Race:*
Ethnicity:
Insured

YesNo
Policy holder name
policy holder date of birth
Insurance Company name
Insurance Policy Number
Insurance group number
Upload image of front and back of insurance card if available

Browse Files

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Section 1

*If YES and further guidance is needed, refer to Pfizer website at www.PfizerMedInfo.com or call 1-800-438-1985 for vaccine information on vaccine temperature excursions, efficacy, safety, stability, dosage, vaccine ingredients, mechanism of action and administration. For 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? If yes, date?*

YESNO
If yes, date?
Do you have a fever today? Are you sick today? Do you have COVID-19 infection and are currently in isolation? Are you currently in quarantine for known exposure to COVID-19?*

YESNO
Have you ever had severe allergic reaction (anaphylactic 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, bad rash all over your body, dizziness, and weakness.*

YESNO
Are you pregnant, breastfeeding or planning to become pregnant? Women in this group may Receive Pfizer-BioNTech or Moderna COVID-19 vaccine, a discussion with your healthcare provider can help make informed decision.*

YESNO
Do you have a bleeding disorder or are you taking a blood thinner?*

YESNO
Are you immunocompromised or have HIV, cancer, chronic kidney, lung, heart disease, sickle cell, severe obesity, do you smoke or have diabetes, mellitus? Are you receiving any immunosuppressive therapy? These individuals may still receive Pfizer-BioNTech or Moderna COVID-19 vaccine unless otherwise contraindicated.*

YESNO
Have you had history of heparin-induced thrombocytopenia? If it has been 90 days or less since illness resolved, you may receive Pfizer-BioNTech or Moderna COVID-19 vaccine. After 90 days since illness resolved, you may be vaccinated with any FDA-authorized COVID-19 vaccine.*

YESNO
NOTE:

Depending on vaccine type, a second dose of COVID-19 vaccine may be due in 21 days or 28 days after initial vaccine. Refer to your COVID-19 vaccination record card for 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.
Section 2: 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 Fact Sheet for each vaccine visit the website www.cvdvaccine.com: or you may also visit the Local Health Unit or private provider to receive a printed copy of the EUA Fact Sheet. 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) - I give consent to this COVID-19 provider/staff for the individual named below to be vaccinated with COVID-19 vaccine. - I hereby acknowledge that I have reviewed a copy of the Provider's Privacy Notice. -I understand that information about the COVID-19 vaccination will be included in (WebIZ) 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.
My signature below indicates I have read, understand and agree to sections 2. Release and Assignment of the COVID-19 Immunization Consent Form and Vaccine recipient Emergency Use of Authorization Fact Sheet (EUA).*

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Date*

MonthDayYear
Date
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COVID Immunization Consent Form

Section 1

NOTE:

Section 2: Release and Assignment: