First Name: Last Name: ____________ M.I: Gender: M ☐ F ☐
DOB: Age: Mother’s Maiden Name: ______________________________________________
Phone: Email: ______
Home Address: City: ________ State: Zip code: _____
Hispanic/Latino?: Y ☐ N ☐ Race: White ☐ Asian ☐ Black ☐ Pacific Islander☐ Native American ☐ Other ☐
1. Are you feeling sick today?
2. Have you ever received a dose of COVID-19 vaccine?
• If yes, which vaccine product did you receive?
☐ Pfizer ☐ Moderna ☐ Another product _____________________________________________________
3. Have you ever had an allergic reaction to:
• A component of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in
some medications, such as laxatives and preparations for colonoscopy procedures
• A previous dose of COVID-19 vaccine
4. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an
injectable medication?
5. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a
component of COVID-19 vaccine, polysorbate, or any vaccine or injectable medication? This would
include food, pet, environmental, or oral medication allergies.
6. Have you received any vaccine in the last 14 days?
7. Have you ever had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?
8. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as
treatment for COVID-19?
9. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take
immunosuppressive drugs or therapies?
10. Do you have a bleeding disorder or are you taking a blood thinner?
11. Are you pregnant or breastfeeding?
Do you have health insurance? Y ☐ N ☐ Insurance Co. Name:________________________________________________
ID Number:__________________ Subscriber’s Name:___________________________ Subscriber’s Birth Date: __________
Consent for Treatment and Privacy Notice
I certify that the information I have provided is true and accurate. I have had a chance to review the Covid-19 vaccine Information (EUA Fact Sheet) and consent to
receive the vaccine. I have had a chance to ask questions, which were answered to my satisfaction. I believe I understand the benefits and risks of the vaccine. I
understand and agree that information related to my vaccine administration may be recorded in the Utah Statewide Immunization Information System (USIIS). I hereby
release Southwest Utah Public Health Department (SWUPHD), and its employees, from all claims arising from such immunizations. We are required to inform you of
our privacy practices for the information we collect and keep about you. I have been given a copy of the Health Department’s Notice of Privacy Practices and have had
an opportunity to ask questions about how my information may be used.
Signature:______________________________________________________ Date: _______________________________________
Relationship to Client: Self ☐ Parent ☐ Legal Guardian ☐ Other ☐ ________________________________
Local Health Department Nurse Use
COVID-19 Vaccine Consent Form
click to sign
signature
click to edit
![]()
