COVID-19 Vaccine Intake Consent Form
For vaccine recipients:
NAME:
____________________________________________________________
The following questions will help us determine if
DATE OF BIRTH: _________________________________________________
there is any reason you should not get the COVID-19
ADDRESS: _________________________________________________
vaccine today. If you answer “yes” to any question,
CITY/STATE/ZIP: _________________________________________________
it does not necessarily mean you should not be vaccinated.
PHONE NUMBER: _________________________________________________
RACE (circle response):
American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific Islander
Black or African American White Unknown Other_______________________
YES NO I DON'T KNOW
1. Have you been diagnosed with, experienced symptoms of, or had close
contact with anyone who has tested positive for COVID-19 in the last 14 days?
2. Are you feeling sick today?
3. Have you ever received a dose of COVID-19 vaccine?
• If y
es, which vaccine product did you receive? Please circle.
Pfizer Moderna Janssen (J&J) Other Product
4. Have you ever had an allergic reaction to
(This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you
to go to the hospital. It would also include an allergic reaction that caused hives, swelling, or respiratory distress, including wheezing.)
• A component of a COVID-19 vaccine, including either of the following:
○ Polyethylene glycol (PEG), which is found in some medications,
laxatives and preparations for colonoscopy procedures
○ Polysorbate, which is found in some vaccines, film coated
tablets, and intr
avenous steroids
• A previous dose of COVID-19 vaccine
5. Have you ever had an allergic reaction to another vaccine
(other than COVID-19 vaccine) or an injectable medication?
6. Check all that apply to you:
Am a female between ages 18 and 49 years old Had COVID-19 and was treated with monoclonal
Am a male between ages 12 and 29 years old
antibodies or convalescent serum
Have a history of myocarditis or pericarditis Diagnosed with Multisystem Inflammatory Syndrome
Had a severe allergic reaction to something other than
(MIS-C or MIS-A) after a COVID-19 infection
a vaccine or injectable therapy such as food, pet,
Have a bleeding disorder
venom, environmental or oral medication allergies
Take a blood thinner
Have a history of heparin-induced thrombocytopenia Am currently pregnant or breastfeeding
History of Guillain-Barré Syndrome (GBS)
DA
TE VIS/EUA WAS GIVEN_____________________________
