Fillable COVID-19 Vaccine Screening and Consent Form

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COVID-19 Vaccine Screening and Consent Form

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The COVID-19 Vaccine Screening and Consent Form form is 2 pages long and contains:

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  • 31 other fields

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COVID-19 Vaccine Screening and Consent Form
Patient Information
Name: ___________________________________ Birth date: ___/___/_____ Age: _______ Sex: ☐ Male ☐ Female
Race: ☐Asian ☐Black ☐Native American ☐Pacific Islander ☐White ☐Other Ethnicity: ☐Hispanic ☐Non-Hispanic
Address: _________________________________ City: _________________________ State: ______ Zip: __________
Phone: __________________________________ Do you have insurance? Yes No
Insurance Company: ____________________________ RX BIN: ____________ RX Group: _______________________
RX ID: __________________________ Relation to Subscriber: ___________________ Person Code: ______________
The following questions will help us determine if there is any reason you should not get the COVID-19 vaccine
today. If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just
means additional questions may be asked. If a question is not clear, please ask your healthcare provider to explain
1. Have you received a dose of COVID-19 Vaccine
If yes which one Pfizer, Moderna, or J&J? _________________
Date? _________________
2. Are you feeling sick today?
3. 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, such as laxatives and
preparations for colonoscopy procedures
• Polysorbate, which is found in some vaccines, film coated tablets, and intravenous
steroids
• 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. Check all that apply to you :
Am a female between ages 18 and 49 years old
Am a male between ages 12 and 29 years old
Have a history of myocarditis or pericarditis
Had a severe allergic reaction to something other than a vaccine or injectable therapy such as
food, pet, venom, environmental or oral medication allergies
Had COVID-19 and was treated with monoclonal antibodies or convalescent serum
Diagnosed with Multisystem Inflammatory Syndrome (MIS-C or MIS-A) after a COVID-19
infection
Have a weakened immune system (i.e., HIV infection, cancer)
Take immunosuppressive drugs or therapies
Have a bleeding disorder or take any blood thinners
Am currently pregnant or breastfeeding
Have received dermal fillers
Yes No
select vaccine
o If I have health insurance that covers myself or the child named above, I give permission for my insurance
company to be billed for the costs of administering the vaccine being administered. The government is
paying for the COVID-19 Vaccine itself, and I will not be billed for that portion of the cost of my immunization.
o I understand that as required by state law, all immunizations will be reported to the Department of Public
Health Massachusetts Immunization Information System (MIIS). I can access the MIIS Fact Sheet for Parents
and Patients, at www.mass.gov/dph/miis, for information on the MIIS and what to do if I object to my or my
family’s data being shared with other providers in the MIIS.
o I have read, or have had explained to me, the Emergency Use Authorization (EUA) for COVID-19 vaccine. I
have had a chance to ask questions that were answered to my satisfaction. I believe I understand the benefits
and risks of COVID-19 vaccine and ask that the vaccine be given to me or the person named above for
whom I am authorized to make this request (parent or guardian).
o I have been advised to wait 15-30 minutes for observation after the administration of the vaccine
Please print name of signature if different from person receiving vaccine ____________________________________
Patient or Parent/Guardian Signature________________________________________________Date______________
__________________________________FOR PHARMACY USE ONLY________________________________________
MA Vaccines For Children Program Eligibility (circle):
VFC Eligible-Medicaid or VFC Eligible-Uninsured or VFC Eligible-American Indian/Alaskan native or Not VFC
Eligible
Date vaccine administered: ____/____/_____ Date EUA/VIS provided: ____/_____/_____
Vaccine manufacturer (Circle): Moderna or Pfizer or Janssen (J&J) Lot number: ________________
Site of IM injection (Circle): RDT or LDT Dose (Circle): 0.5m or 0.3ml
Signature of Vaccine Provider: ______________________________________________________________________
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COVID-19 Vaccine Screening and Consent Form

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Completed 5 August 2021

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