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COVID-19 IMMUNIZATION CONSENT FORM

Person Receiving Vaccine

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Medical History

Complete the following questions for the individual receiving the vaccine.If you answer “YES”, the patient may not be able to receive the COVID-19 vaccine.
Have you received a COVID-19 vaccine outside of your scheduled series?*
Have you had any vaccines within the previous 14 days? Pfizer-BioNTech, Moderna, or Janssen COVID- 19 vaccine should be administered alone with minimal interval of 14 days before or after any other vaccine.*
Do you have a fever today?*
Do you have COVID-19 infection and are currently in isolation? Are you currently in quarantine for known exposure to COVID-19?*
Have you ever had severe allergic reaction (anaphylactic reaction) to any vaccine, vaccine component (including polyethylene glycol [PEG], or immediate allergic reaction of any severity to polysorbate (due to potential cross-reactive hypersensitivity with the vaccine ingredient PEG) or injectable therapy? (including Pfizer-BioNTech, Moderna, or Janssen COVID-19 vaccine) Such as difficulty breathing, swelling of your face and throat, fast heartbeat, bad rash all over your body, dizziness and weakness.*
Have you received monoclonal antibodies or convalescent plasma as part of COVID-19 treatment? Pfizer- BioNTech, Moderna, or Janssen COVID-19 vaccine should be deferred for at least 90 days to avoid interference of treatment with vaccine-induced immune responses.*

NOTE:

Depending on vaccine type, a second dose of COVID-19 vaccine may be due in 21 days for Pfizer-BioNTech or 28 days after initial vaccine for Moderna. Janssen COVID-19 vaccine is a ONE dose series. Refer to your COVID-19 vaccination record card for second dose due date if applicable. Keep your COVID-19 vaccination record cardfor your records for proof of initial vaccine date.

Release and Assignment

Privacy*

Please read the information below. The CrescentCare Privacy Notice is available at the on its website www.crescentcare.org or is available upon request.

COVID-19 IMMUNIZATION CONSENT FORM

To read the Vaccine Recipient EUA Fact Sheet for Pfizer COVID-19 vaccine, Moderna COVID-19 vaccine, or Janssen COVID-19 vaccine visit https://www.cdc.gov/vaccines/covid-19/eua/index.html.

  • I have received Emergency Use Authorization of the COVID-19 Vaccine Fact Sheet for Recipients and Caregivers about the COVID-19 vaccine and have had a chance to ask questions and had them answered to my satisfaction.
  • I understand that the common side effects for adults include soreness and redness at the injection site, fever, muscle aches, headaches, and tiredness.
  • I have read the inform provided on this form and I have answered all questions honestly.
  • I give my permission to release this COVID-19 information to other medical providers to avoid unnecessary vaccinations and to determine immunization status.
  • I understand that I am to wait 15 minutes after receiving the COVID vaccine before leaving the building.
  • I understand the benefits and risks of the COVID-19 vaccine and I hereby authorize and consent to receive the vaccination.

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.

We encourage you to discuss the following conditions with your primary care provider. However, you are still eligible to receive Moderna, Pfizer-BioNTech or Janssen COVID vaccine.

  • Have a bleeding disorder or are on a blood thinner.
  • Are immunocompromised or are on a medicine that affects your immune system
  • Are pregnant or plan to become pregnant
  • Are breastfeeding

Signature of Patient/Parent/Guardian:

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