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Covid-19 Vaccine Consent Form: Information About Person To Receive Vaccine (Please Print)

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Karylle Petil

This document is a COVID-19 vaccine consent form that collects information about the person receiving the vaccine, including their medical history and insurance details. It asks questions to determine if there are any reasons they should not receive the vaccine. If approved for vaccination, the form requires signatures from the client/guardian and vaccine administrator. It collects basic identification and contact information as well as insurance coverage. The form aims to properly screen and document those receiving the COVID-19 vaccine.

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Download as docx, pdf, or txt

Covid-19 Vaccine Consent Form: Information About Person To Receive Vaccine (Please Print)

Uploaded by

Karylle Petil
111 views2 pages
This document is a COVID-19 vaccine consent form that collects information about the person receiving the vaccine, including their medical history and insurance details. It asks questions to determine if there are any reasons they should not receive the vaccine. If approved for vaccination, the form requires signatures from the client/guardian and vaccine administrator. It collects basic identification and contact information as well as insurance coverage. The form aims to properly screen and document those receiving the COVID-19 vaccine.

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COVID-Vaccine-Consent-Form-Template

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This document is a COVID-19 vaccine consent form that collects information about the person receiving the vaccine, including their medical history and insurance details. It asks questions to determine if there are any reasons they should not receive the vaccine. If approved for vaccination, the form requires signatures from the client/guardian and vaccine administrator. It collects basic identification and contact information as well as insurance coverage. The form aims to properly screen and document those receiving the COVID-19 vaccine.

Copyright:

© All Rights Reserved
Download as DOCX, PDF, TXT or read online from Scribd
Download as docx, pdf, or txt
111 views2 pages

Covid-19 Vaccine Consent Form: Information About Person To Receive Vaccine (Please Print)

Uploaded by

Karylle Petil
This document is a COVID-19 vaccine consent form that collects information about the person receiving the vaccine, including their medical history and insurance details. It asks questions to determine if there are any reasons they should not receive the vaccine. If approved for vaccination, the form requires signatures from the client/guardian and vaccine administrator. It collects basic identification and contact information as well as insurance coverage. The form aims to properly screen and document those receiving the COVID-19 vaccine.

Copyright:

© All Rights Reserved
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COVID-19 VACCINE CONSENT FORM

Information about person to receive vaccine (please print)

Name: ___________________________________ Birth date: ___/___/_____ Age: 20 Sex: ☐ Male ☐ Female

Race: ☐Asian ☐Black ☐Native American ☐Pacific Islander ☐White ☐Other Ethnicity: ☐Hispanic ☐Non-Hispanic

Address: _________________________________ City: ____________________________ State: ______ Zip: _______

Phone: __________________________________ Do you have insurance? ☐ No ☐ Yes

The following questions will help determine if there is any reason you should not receive a COVID
immunization injection.
Answering “yes” to any question does not prevent you from being vaccinated. It means additional questions will be asked. If a
question is not clear, please ask a healthcare provider to explain.

Has the person to be vaccinated ever received a COVID-19 vaccine? ☐ No ☐Yes


If yes, date:________________ Type/Brand of COVID vaccine:_____________________
Does the person to be vaccinated have an allergy to any medications, food, vaccine, or latex? ☐ No ☐Yes
List all allergies: _________________________________________
Has the person to be vaccinated ever had a severe reaction to any vaccine or injectable therapy? ☐ No ☐Yes
Is the person to be vaccinated sick today? ☐ No ☐Yes
Is the person to be vaccinated at least 18 years old? ☐ No ☐Yes
If no, is the person to be vaccinated at least 16 years old? ☐ No ☐Yes
Does the person to be vaccinated have a bleeding disorder or are they taking a blood thinner? ☐ No ☐Yes
Has the person to be vaccinated received any other vaccines in the past 14 days? ☐ No ☐Yes
Has the person to be vaccinated received passive antibody therapy as treatment for COVID-19? ☐ No ☐ Yes

I have read, or have had explained to me, the Emergency Use Authorization (EUA) for COVID-19 vaccine. I have had a chance to
ask questions that were answered to my satisfaction. I believe I understand the benefits and risks of COVID-19 vaccine and ask
that the vaccine be given to me or the person named above for whom I am authorized to make this request (parent or guardian).
I HAVE BEEN ADVISED TO WAIT FOR 15-30 MINUTES OF OBSERVATION AFTER RECEIVING MY VACCINE BEFORE LEAVING.
Print Parent/Guardian name, if different from client: _____________________________________________________

Client/Parent/Guardian Signature: _______________________________________________Date: _______________

______________________________________FOR CLINIC USE ONLY___________________________________________


Clinic site: ________________________________________ EUA Fact Sheet Provided: Yes No
Date vaccine administered: ____/____/_____ Date booster required: ____/_____/_____
Vaccine manufacturer: ___________________________________ Lot number: ________________________
Site of IM injection: RDT or LDT or ___________ Dose: 0.3ml 0.5ml

(12/2020 COVID-19 Consent Form)


COVID-19 VACCINE CONSENT FORM
Signature and title of vaccine administrator: _________________________________________________________________
Nurse’s Comments: ______________________________________________________________________________________

INSURANCE INFORMATION
(Please give your insurance card to the receptionist)

Primary Insurance:
Subscriber’s Name: Date of birth:
Group No:
Policy No:
Client’s relationship to subscriber:

Secondary Insurance:
Subscriber’s Name: Date of birth:
Group No:
Policy No:
Client’s relationship to subscriber:

The above information is true to the best of my knowledge. If qualified, I authorize billing to my insurance company and
release of information required to process my claims.
I authorize my insurance benefits be paid directly to ________________.

Client Signature Date

(12/2020 COVID-19 Consent Form)

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