Fillable COVID-19 VACCINE SCREENING AND CONSENT FORM Date of (ProHealth Professional Services)

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COVID-19 VACCINE SCREENING AND CONSENT FORM Date of (ProHealth Professional Services)

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  • 41 check-boxes
  • 41 other fields

Country of origin: US
File type: PDF

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Prohealth Medical Group
COVID-19 VACCINE SCREENING AND CONSENT FORM
COVID19-1E (12-20)
SECTION 1: INFORMATION ABOUT YOU (PLEASE PRINT)
Last Name
First Name
Middle Name
Date of Birth
Age in Years:
Sex
(Gender assigned at birth)
Male Female
Month
Day
Year
Race
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other
Pacific Islander
White
Other Asian
Other Nonwhite
Other Pacific Islander
Other
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Unknown
City
State
Zip Code
Primary Insurance Carrier ID #:
Grp #:
Insurance Company:
Insurance Company
Phone #
Insured Name: Relationship:
Insured Date of
Birth:
Secondary Insurance Carrier ID#:
Grp #:
Insurance Company:
Insurance Company
Phone #
Insured Name: Relationship:
Insured Date of
Birth:
Is this the patient’s first or second dose of the COVID-19 vaccination?
First Dose Second Dose
SECTION 2: COVID-19 SCREE
NING QUESTIONS
Please check YES or NO for each question.
YES
NO
1. Are you sick today?
2. Have you had a severe allergic reaction to a previous dose of this vaccine or to any of the ingredients of this vaccine?
3. Do you carry an Epi-pen for emergency treatment of anaphylaxis?
4. For women, are you pregnant or is there a chance you could become pregnant?
5. For women, are you breastfeeding?
6. Have you had any other vaccinations in the previous 14 days?
7. In the past two weeks, have you tested positive for COVID-19?
8. Have you had, in the last 10 days, fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches,
headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea, vomiting, or diarrhea?
Vaccination Locations: CVO-Bakersfield CVO-Delano Glendale Valley
SECTION 3:
IMMUNIZATION SCREENING GUIDANCE FOR COVID-19 VACCINE
Please check YES
or NO for each question.
YES
NO
9. Do you have allergies or reactions to any medications, foods, vaccines, or latex? Please explain:
10. Are you immunocompromised or on a medicine that affects your immune system?
11. Do you have a bleeding disorder or are you on a blood thinner/blood-thinning medication?
12. Have you received a previous dose of any COVID-19 vaccine? If yes, which manufacturer’s vaccine did you receive:
I certify that I am: (a) the patient and at least 18 years of age; (b) the parent or legal guardian of the patient and confirm that the
patient is at least 16 years of age; or (c) authorized to consent for vaccination for the patient named above. Further, I hereby give
my consent to Prohealth Medical Group and Clinics, and the California Department of Health (DOH) or its agents to administer the
COVID-19 vaccine.
I understand that this product has not been approved or licensed by FDA, but has been authorized for emergency use by FDA, under
an EUA to prevent Coronavirus Disease 2019 (COVID-19) for use in individuals 18 years of age and older; and the emergency use of
this product is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency
use of the medical product under Section 564(b)(1) of the FD&C Act unless the declaration is terminated or authorization revoked
sooner.
I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccine(s). I
understand the risks and benefits associated with the above vaccine and have received, read and/or had explained to me the
Emergency Use Authorization Fact Sheet on the COVID-19 vaccine I have elected to receive. I also acknowledge that I have had
a chance to ask questions and that such questions were answered to my satisfaction.
I acknowledge that I have been advised to remain near the vaccination location for approximately 15 minutes after
administration for observation. If I experience a severe reaction, I will call 9-1-1 or go to the nearest hospital.
On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless Prohealth Medical Group and It's
associated Clinics, and their staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors and
employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way
related to the administration of the vaccine listed above.
I acknowledge that: (a) I understand the purposes/benefits of California immunization registry and (b) DOH will include my
personal immunization information in California SHOTS and my personal immunization information will be shared with the Centers
for Disease Control (CDC) or other federal agencies.
I further authorize DOH or its agents to submit a claim to my insurance provider or Medicare Part B without supplemental coverage
payment for me for the above requested items and services. I assign and request payment of authorized benefits be made on my
behalf to DOH or its agents with respect to the above requested items and services. I understand that any payment for which I am
financially responsible is due at the time of service or if DOH invoices me after the time of service, upon receipt of such invoice.
I acknowledge receipt of the Notice of Privacy Rights.
Signature of Patient or Authorized Representative:
Date:
Print Name of Representative and Relationship to Person Receiving Vaccine:
Site
(LD/RD)
Route Manufacturer (M
VX)
Lot #Unit o
f Use/ Unit of Sale
Expiration Date
Date of
EUA Fact Sheet
IM
Administered at Location
(Facility Name/ID):
Administered at Location
(Type):
Administration Address:
CVX (Product):
Sending Organization
:
Vaccinator
(Print Name)
:
Signature: Date:
Vaccine Administering Provid
er Suffix:
COVID19-
1E (12-20)
CVO
Glendale
Valley
Delano
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COVID-19 VACCINE SCREENING AND CONSENT FORM Date of (ProHealth Professional Services)

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Completed 15 August 2021

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