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

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    Karylle Petil
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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.

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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.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    96 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
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
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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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