Fillable ACCEPTANCE COVID-19 VACCINE CONSENT FIRST NAME UPPER CASE

Fill Online, Printable, Fillable, Blank ACCEPTANCE COVID-19 VACCINE CONSENT FIRST NAME UPPER CASE Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

ACCEPTANCE COVID-19 VACCINE CONSENT FIRST NAME UPPER CASE

On average this form takes 9 minutes to complete

The ACCEPTANCE COVID-19 VACCINE CONSENT FIRST NAME UPPER CASE form is 2 pages long and contains:

  • 0 signatures
  • 6 check-boxes
  • 34 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
ACCEPTANCE
COVID-19 VACCINE CONSENT
WHITE – KECK MEDICINE OF USC
COPY – EMPOLYEE/PATIENT
314/363-5620 (3-21)
CONSENT FOR COVID-19 VACCINE
Page 1 of 2
FIRST NAME
(
UPPER CASE
)
LAST NAME (UPPER CASE)
Date of Birth (MM/DD/YYYY):
________________________
Gender:
□
Female
□
Male
□
Non-Binary
Emergency Contact Name:
__________________________
Emergency Contact Number:
_______________________________
SECTION I: PURPOSE OF INFORMED CONSENT
At the current time, there are no Food and Drug Administration (FDA) approved COVID-19 vaccinations. However, based on
promising evidence, the FDA issued an Emergency Use Authorization (EUA) to permit the emergency use of 3 unapproved
products: Pfizer-BioNTech, Moderna, and Janssen COVID-19 Vaccines. These vaccines have been granted EUA to prevent
COVID-19 in individuals 16 years of age and older for Pfizer-BioNTech and 18 years of age and older for Moderna and Janssen.
SECTION II: Screening for POSSIBLE CONTRAINDICATIONS
YES NO CHECK THE APPROPRIATE BOX
□
□
1. Do you have any of the following? Fever, Shortness of breath, sore throat, chills, congestion,
runny nose, diarrhea, nausea, or vomiting
□
□
2. Have you received a dose of COVID 19 vaccine?
If yes, which one? Manufacturer________________ Date:_______________
□
□
3. Have you had an allergic reaction of any severity to a previous dose of an mRNA COVID-19
vaccine or any of its components? Please see below for components
If yes, please describe reaction: _______________________________________________
____________________________________________________________________
SECTION III: Screening for PRECAUTIONARY CRITERIA
Y
ES NO CHECK THE APPROPRIATE BOX
□
□
4. Have you ever had a severe allergic reaction to any vaccine, injectable therapies, food, pet,
venom, environmental allergies, or oral medications for which you were treated with
epinephrine or EpiPen, or for which you had to go to the hospital?
314/363-5620 (3-21)
WHITE – KECK MEDICINE OF USC
COPY – EMPOLYEE/PATIENT
CONSENT FOR COVID-19 VACCINE
Page 2 of 2
□ □
5. If answered yes to question 4, have you consulted your physician to determine that a COVID-
19 vaccine is appropriate for you?
SECTION IV: Screening for conditions in which delayed vaccination may be recommended
Due to concerns for diminished benefit, COVID-19 vaccination is recommended after a specified amount of time has elapsed for
the conditions listed below:
YES NO CHECK THE APPROPRIATE BOX
□ □
6. Have you had confirmed COVID-19 disease within previous 90 days?
Must wait at least 10 days from positive test result, feel better and be with no fever before getting a
covid
-
19 vaccine. Ma
y
wait 90 da
y
s, as unlikel
y
to get re-infected based on available data
□ □
7. Have you received COVID-19 monoclonal antibodies or convalescent plasma within the
previous 90 da
y
s?
□ □
8. Have you received any vaccination in the past 14 days?
SECTION V: Receipt of Vaccine Fact Sheet
In order to receive the COVID-19 vaccine, indicate that the following have been provided and/or discussed with you by
checking each box:
□ I was provided a copy of the “Fact Sheet for Recipients and Caregivers” for □ Pfizer-BioNTech, □ Moderna, or □ Janssen
COVID-19 vaccine.
□ My questions/concerns about the vaccine have been addressed to my satisfaction.
SECTION VI: YOUR ACKNOWLEDGMENT/CONSENT AND SIGNATURE
□ I attest that I am eligible to receive a COVID-19 vaccine in accordance with the Los Angeles County Department of Public
Health's COVID-19 Vaccine Distribution policy
□ I have read or had explained to me the “Fact Sheet for Recipients and Caregivers” and I understand the risks and benefits
□ I GIVE CONSENT to receiving the entire vaccine schedule
□ 2 doses Pfizer-BioNTech COVID-19 Vaccine
□ 2 doses Moderna COVID-19 Vaccine
□ 1 dose Janssen COVID-19 Vaccine
For those receiving either Pfizer-BioNTech or Moderna COVID-19 vaccine
□ I UNDERSTAND that, prior to the second dose, I will be asked a series of screening questions by clinical staff to determine
whether it is appropriate for me to receive the second dose of the COVID-19 Vaccine
Signature Date
For additional questions please refer to following websites:
1. https://www.cdc.gov/vaccines/covid-19/index.html
2. https://www.keckmedicine.org/coronavirus-vaccine/
DOWNTIME USE ONLY
Vaccine – Fact Sheet dated Feb 2021 0.3 mL IM
DATE
GIVEN
MANUFACTURER LOT NO. EXP. DATE INJECTION SITE
ADMINISTERED BY (PRINT NAME)
/ /
□
Right Deltoid
□
Left Deltoid
/ /
□
Right Deltoid
□
Left Deltoid
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

ACCEPTANCE COVID-19 VACCINE CONSENT FIRST NAME UPPER CASE

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 3 April 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document