COVID-19 VACCINATION CONSENT
Mason Health, 901 Mountain View Dr.,
P.O. Box 1668, Shelton, WA 98584
MGH 1695 Rev. 4/2021 SCAN TO CONSENT FORM
Date of Birth:
1. What is your race?
☐ American Indian or Alaska Native ☐ Asian
☐ Black or African American ☐ Native Hawaiian or other Pacific Islander
☐ White ☐ Multi-Racial or other (please specify) __________________
☐ Latino or Hispanic origin ☐ Decline to answer
2. Vaccine Dose (check one): 1
st
☐ 2
nd
☐ If this is your second dose, what vaccine was your first?
Pfizer ☐ Moderna ☐ Don’t know ☐
If this is your second dose, when did you receive your first dose? (date): ___________________.
EXCLUSION QUESTIONS: Answering yes to this question excludes you from receiving the vaccine.
Do you have a known history of a severe allergic reaction (e.g. anaphylaxis) to this vaccine or any
components of the vaccine such as lipids, potassium chloride, monobasic potassium phosphate, sodium
chloride, dibasic sodium phosphate dihydrate, tromethamine, tromethamine hydrochloride, acetic acid,
sodium acetate and sucrose? (Full list is available in the Fact Sheet for Vaccine Recipients and
Caregivers or from your health care provider.)
SCREENING QUESTIONS: Immunizer: If patient answers “yes” to any of the below, provide patient
counseling or instruct them to consult with their caregiver prior to receiving the vaccine
1. In the past 90 days have you received passive antibody therapy as part of COVID-19 treatment? Keep
2. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an
injectable medication? (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 to food, latex, pet, environmental, or medication allergies that occurred within 4
hours that caused hives, swelling, or respiratory distress, including wheezing.)
3. Have you ever had a serious reaction after receiving an injectable medication? If yes, what injectable
medication: __________________________________
4. Do you have a history of fainting, particularly with vaccines? Has any physician or other health care
provider ever cautioned you about receiving certain vaccines or receiving vaccines outside of a medical
setting?
5. Do you have cancer, leukemia, HIV/AIDS, rheumatoid arthritis, ankylosing spondylitis, Crohn’s
disease, or any other immune system problem? Do you have a weakened immune system or in the past
three months, taken medications that weaken it, such as cortisone, prednisone, or other steroids,
anticancer drugs, immunosuppressive drugs or therapies, or radiation treatments?
6. For women, are you pregnant or is there a chance you could become pregnant during the next month?
7. Have you received any vaccinations in the past two weeks?
Acknowledgements:
• I made the choice to get the COVID-19 vaccine on my own and freely. I know I have the option to refuse the
vaccine. I ask that the vaccine be given to me, or to the person named above for whom I can make this request.
I was given the (Fact Sheet for Vaccine Recipients and Caregivers) for this vaccine. The fact sheet has
information about side effects and adverse reactions. I read or had read to me the information provided about
the COVID-19 vaccine.
• I know the Food and Drug Administration (FDA) has authorized the emergency use of this vaccine. I know it
is not a fully licensed FDA vaccine. I had the chance to ask questions that were answered to my satisfaction. I
now know about the vaccine, alternatives, benefits, and risks, to the extent they are known and unknown at
this time.
• I know that I must stay in the vaccine area or an area told to me by my health care provider after I receive my
immunization so I am near my health care provider if I have any adverse reactions. If I have a history of
