Clinic Information
Clinic ID Clinic Name Telephone
Address City State Zip
Patient Information
Last Name First Name Date of Birth Gender
Address City State Zip
Primary Care Provider (PCP) Name PCP Phone Number PCP Fax Number
PCP Address City State Zip
Are you a resident of a Long Term Care facility or an employee
Is this the patients first
or second dose of the COVID-19 vaccination?
Insurance Information: (For onsite clinics, please ensure a copy of the patients insurance card(s) was collected)
Prescription Insurance:
*Are you the primary cardholder? *If no, include the primary cardholder’s DOB
*Cardholder ID # *RX Group ID *BIN *PCN
Medicare Fields:
*Is the Patient age 65 or older *Medicare Part A/B ID Number (MBI) Note: MBI is required for all patients age 65 and
or Medicare Eligible? older, or Medicare eligible. Refer to your Medicare Red, White, and Blue card
Medical Insurance:
*Medical Insurance Provider *Cardholder ID # *Group ID *Payer ID
*Is the patient the primary cardholder? *If no, include primary cardholders DOB
I I do not have any insurance, including but not limited to Medicare, Medicaid or any other private or government-funded
In order to have your vaccine administration fee paid for by the United States Health Resources & Services Administration’s
Potential Contraindications YES NO
Are you feeling sick today?
Have you ever received a dose of COVID-19 vaccine?
If yes, which vaccine product? Moderna Another product:
Example: a reaction for
which you were treated with epinephrine or EpiPen®, or for which you had to go to the hospital?
Was the severe allergic reaction after receiving a COVID-19 vaccine?
Was the severe allergic reaction after receiving another vaccine or injectable medication?
Was the severe allergic reaction related to receiving Polyethylene Glycol or products containing
Polyethylene Glycol?
Was the severe allergic reaction related to receiving Polysorbate or products containing Polysorbate?
Yes No
Yes No
Yes No
Form 1 of 2 to be completed
COVID Vaccine Intake Consent Form
Phone Number
Do you have any other drug related allergies? if yes, please list:
Email Address
UnitedAg Health & Wellness Center
1235 Rose Ave.
Potential Contraindications YES NO
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
Do you have a bleeding disorder or are you taking a blood thinner?
For women, are you currently pregnant or breastfeeding?
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
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
1 - Hispanic 2 - Not Hispanic or Latino 3 - Unknown
Phone Number Relationship
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
Last Name First Name Date of Birth
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.