Page 1 of 2 Moderna COVID-19 Vaccine
Effective Date: 1/04/2021
Moderna COVID-19 Vaccine
Name: Last: First: Middle Initial:
Date of Birth: Month Day Year Mobile Phone Number (Patient or Guardian): ( )
Address: Apt/Room #:
City: State: Zip:
Sex (Gender assigned at birth)
American Indian or Alaska Native Native Hawaiian or other Other Asian Unknown
Asian Pacific Islander Other Nonwhite
Black or African American White Other Pacific Islander
Hispanic or Latino
Not Hispanic or Latino
Primary Insurance Carrier ID #: ______________________Grp #: ____________________
Insurance Company : ____________________________________________Insurance Company Phone #_____________________
Insured’s Name:________________________________Relationship:_______________________Insured’s Date of Birth___________
Secondary Insurance Carrier ID #: ______________________Grp #: ____________________
Insurance Company : ____________________________________________Insurance Company Phone #_____________________
Insured’s Name:________________________________Relationship:_______________________Insured’s Date of Birth___________
Is this the patient’s first or second dose of the COVID-19 vaccination? First Dose Second Dose
Please check YES or No for each question.
1. Do you have today or have you had at any time in the last 10 days a fever, chills, cough, shortness of breath, difficulty
breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose,
nausea, vomiting, or diarrhea?
2. Have you tested positive for and/or been diagnosed with COVID-19 infection within the last 10 days?
3. Have you had a severe allergic reaction (e.g. needed epinephrine or hospital care) to a previous dose of this vaccine or to
any of the ingredients of this vaccine?
4. Have you had any other vaccinations in the last 14 days (e.g. influenza vaccine, etc.)?
5. Have you had any COVID-19 Antibody therapy within the last 90 days (e.g. Regeneron, Bamlanivimab, COVID Convalescent
Plasma, etc.)
Please check YES or No for each question.
6. Do you carry an Epi-pen for emergency treatment of anaphylaxis and/or have allergies or reactions to any medications,
foods, vaccines or latex?
7. For women, are you pregnant or is there a chance you could become pregnant?
8. For women, are you currently breastfeeding?
9. Are you immunocompromised or on a medication that affects your immune system?
10. Do you have a bleeding disorder or are you on a blood thinner/blood-thinning medication?
11. Have you received a previous dose of any COVID-19 vaccine? If yes, which manufacturer’s vaccine did you receive:
I certify that I am: (a) the patient and at least 18 years of age; (b) the legal guardian of the patient and confirm that the patient is at least 18
years of age; or (c) authorized to consent for vaccination for the patient named above. Further, I hereby give my consent to the Florida
Department of Health (DOH) or its agents to administer the COVID-19 vaccine.
I understand that this product has not been approved or licensed by FDA, but has been authorized for emergency use by FDA, under an EUA to
prevent Coronavirus Disease 2019 (COVID-19) for use in individuals 18 years of age and older; and the emergency use of this product is only
Administration Facility Name/Facility ID: ______________________________________
Page 2 of 2 Moderna COVID-19 Vaccine
Effective Date: 1/04/2021
authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of the medical product under
Section 564(b)(1) of the FD&C Act unless the declaration is terminated or authorization revoked sooner.
I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccine(s). I understand the
risks and benefits associated with the above vaccine and have received, read and/or had explained to me the Emergency Use Authorization
Fact Sheet on the COVID-19 vaccine I have elected to receive. I also acknowledge that I have had a chance to ask questions and that such
questions were answered to my satisfaction.
I acknowledge that I have been advised to remain near the vaccination location for approximately 15 minutes (or more in specific cases) after
administration for observation. If I experience a severe reaction, I will call 9-1-1 or go to the nearest hospital.
On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless the State of Florida, the Florida Department of
Health (DOH), and their staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors and employees from any and
all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the vaccine
listed above.
I acknowledge that: (a) I understand the purposes/benefits of Florida SHOTS, Florida’s immunization registry and (b) DOH will include my
personal immunization information in Florida SHOTS and my personal immunization information will be shared with the Centers for Disease
Control (CDC) or other federal agencies.
I further authorize DOH or its agents to submit a claim to my insurance provider or Medicare Part B without supplemental coverage payment for
me for the above requested items and services. I assign and request payment of authorized benefits be made on my behalf to DOH or its
agents with respect to the above requested items and services. I understand that any payment for which I am financially responsible is due at
the time of service or if DOH invoices me after the time of service, upon receipt of such invoice.
I acknowledge receipt of the Notice of Privacy Rights.
Signature of Patient or Authorized Representative Date:
Print Name of Representative and Relationship to Person Receiving Vaccine: __________________________________________________
Manufacturer (MVX)
Lot #
Unit of Use/
Unit of Sale
Expiration Date
Date of EUA Fact Sheet
Administered at location: facility
Administered at location: Type
Administration Address:
CVX (product)
Sending organization:
Vaccinator Print Name:___________________________________________ Signature: ____________________________________ Date: _______________
Vaccine administering provider suffix: _____________________________________________