Potential Contraindications YES NO
DON’T
KNOW
Have you received any vaccines in the past 14 days?
Have you received monoclonal antibodies or convalescent plasma as part of a COVID-19 treatment
in the past 90 days?
Potential Considerations YES NO
DON’T
KNOW
Do you have a bleeding disorder or are you taking a blood thinner?
For women, are you currently pregnant or breastfeeding?
X
Signature of patient to receive vaccine (or parent, guardian, or authorized representative) Date
If signing on behalf of the patient, you are stating that you are authorized to provide the required consents on behalf of the patient.
Vaccine Administration Information for Immunizer/Pharmacist use only
Administration Date Vaccine VIS Date Manufacturer Volume (mL)
Patient Temperature
MS:
OK: Check Race and Ethnicity Next of Kin
Race: 1 - American Indian or Alaska Native 2 - Asian 3
4 - Black or African American 5 - White 6 - Other Race
Ethnicity:
1 - Hispanic 2 - Not Hispanic or Latino 3 - Unknown
Name
Phone Number Relationship
Address
State of NJ only
Prescriber Name Prescriber Address
For CA, MA, MT, NJ, NM, NY, TX (For CA, this indicator means the registry will not share with Universities, Schools or
other agencies) Registry Sharing Indicator:
Yes No
L R
Last Name First Name Date of Birth
continued
Form 2 of 2 to be completed
(If patients body temperature is 100.4 degrees F or greater, inform them they should not recieve the vaccine at this time.)
CONSENT FOR SERVICES: I have been provided with the Vaccine Information
Sheet(s) or patient fact sheet corresponding to the vaccine(s) that I am receiving. I
have read the information provided about the vaccine I am to receive. I have had the
chance to ask questions that were answered to my satisfaction. I understand the
benefits and risks of vaccination and I voluntarily assume full responsibility for any
reactions that may result. I understand that I should remain in the vaccine adminis-
tration area for 15 minutes after the vaccination to be monitored for any potential
adverse reactions. I understand if I experience side effects that I should do the
following: call pharmacy, contact doctor, call 911. I request that the vaccine be given
to me or to the person named above for whom I am authorized to make this request.
AUTHORIZATION TO REQUEST PAYMENT: I do hereby authorize Elite Corporate
Medical Services, Inc. (“ECMS”) to release information and request payment. I certify
that the information given by me in applying for payment under Medicare or
Medicaid, or the HRSA COVID-19 Program for Uninsured Patients, is correct. I
authorize release of all records to act on this request. I request that payment of
authorized benefits be made on my behalf.
DISCLOSURE OF RECORDS: I understand that ECMS may be required to or may
voluntarily disclose my health information to the physician responsible for this
protocol of specific health information of people vaccinated at ECMS (if applicable),
my Primary Care Physician (if I have one), my insurance plan, health systems and
hospitals, and/or state or federal registries, for purposes of treatment, payment or
other health care operations (such as administration or quality assurance). I also
understand that ECMS will use and disclose my health information as set forth in
the Privacy Practices. State of California only: I agree to have CAIR share my
immunization data with Health Care Providers, agencies or schools. Vaccine
Clinics: If I am receiving a vaccine through a vaccine clinic, I understand that my
name, vaccine appointment date and time will be provided to the clinic coordinator.
