ADHS COVID-19 Vaccine Consent Form
Use this form in conjunction with the CDC Pre-Vaccination Checklist for
COVID-19 Vaccines.
Patient Information
(Staff only) Appointment ID:
Last Name
First Name
Middle Name (optional)
Mother’s Maiden Name (Optional)
Date of Birth (MM/DD/YYYY)
Gender
Address
No address available
Insurance Information
Do you have insurance?
Apartment Number
Yes No
City State
Zip
Phone Number
Email Address
Plan Name
Plan Group ID #
Plan Individual ID #
Name of Person Covered By Plan Plan Responsible Person Name
Private Insurance Address and Phone Number (If Available)
CONSENT AND ASSIGNMENT OF BENEFITS: I have had a copy of the Emergency Use Authorization for the COVID-19 vaccine made available to me. I have had a
chance to ask questions and I believe I understand the benefits and risks of the COVID-19 vaccines requested. I ask that the vaccines be administered to me or the
person for whom I am authorized to make this request.
I certify that I am: (1) the patient and at least 18 years of age; (2) the legal guardian of the patient and the patient's age makes him/her eligible to receive the vaccine based
on the current emergency use authorization; or (3) a person authorized to consent on behalf of the patient where the patient is unable to consent for themselves.
I hereby assign to _______________________________________ any insurance or other third-party benefits available for the administration fee of the COVID-19 vaccine
provided to me. I agree to forward to _________________________________________ all health insurance and other third-party payments I receive for services
rendered to me immediately upon receipt.
I agree to allow the health care provider to release information to the Arizona State Immunization Information System (ASIIS) to record that I (or for the person for whom I
am authorized to consent) have received this COVID-19 vaccine. This information will help keep track of the manufacturer and doses of the vaccine.
Patient Printed Name
Patient Signature
Date Signed
Parent/Guardian/Authorized Person Printed Name
Authorized Person’s Signature
Date Signed
Vaccine Administration Information for Immunizer Use Only
Administration Date
Manufacturer
NDC #
LEFT ARM
RIGHT ARM
Lot Number
Expiration Date
Route Site
Signature
Administering Immunizer Name and Title
Is this the patient’s first, second, or third dose?
First
Administering Immunizer
Second
Third
Booster Dose
