Patient # ______________________
COVID-19 VACCINE CONSENT FORM
PLEASE PRINT INFORMATION FOR PERSON RECEIVING VACCINE
Last Name, First Name, Middle Initial
Date of Birth (mm/dd/yyyy)
( )
Race – You May Check More Than One Category
African American Asian American Indian/Alaska Native
Native Hawaiian/Pacific Islander White Other
Hispanic
Male
Are you currently pregnant
or breastfeeding? Yes No
Do you have an immunocompromising condition?
Yes No
Have you ever received a COVID-19 vaccine before? Yes No
IF YES, date vaccine received: ______________ and vaccine manufacturer: _____________________________
Do you have a bleeding disorder or are you currently taking a blood thinner?
Are you sick today, or have you had a fever in the past two days?
Are you currently under COVID-19 isolation (infected with COVID-19) or quarantine (exposed to
someone with COVID-19) precautions?
Have you received monocolonal antibody therapy or convalescent plasma for COVID-19
treatment in the past 90 days?
Have you had any vaccine within the past 14 days, or do you plan to receive another vaccine within
the next 14 days?
Have you EVER had an immediate or severe (life-threatening) allergic reaction after a dose of any
vaccine or injectable medication?
Do you have a known allergy to a component of any other authorized COVID-19 vaccine?
Have you EVER had an immediate or severe (life-threatening) allergic reaction to any component
of this vaccine as detailed in the Emergency Use Authorization Fact Sheet?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
I (person receiving vaccine) have:
• received, read, and understand the Emergency Use Authorization Fact Sheet and/or Vaccine Information
Statement for the vaccine I am receiving;
• received the Cobb & Douglas Public Health HIPAA Notice of Provider Privacy Practices;
• had the opportunity to discuss any medical concerns with my healthcare provider or a healthcare
provider at the time of my vaccination.
PLEASE ASK QUESTIONS BEFORE RECEIVING THE COVID-19 VACCINE.
I understand the risks of this vaccine and ask that this vaccine be given to me or to the person named
above for whom I am authorized to make this request
_________________________________________________
Signature
_________________________________________________
_________________________
Date
_________________________
Relationship to Patient (If Applicable)
FOR COBB & DOUGLAS PUBLIC HEALTH USE ONLY
_______________________________________
Vaccinator Printed Name
_______________________________________
Vaccinator Signature / Title
Updated 3/17/2021
Yes
No
