Fillable Moderna COVID-19 Vaccine (Mowery Clinic)

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Moderna COVID-19 Vaccine (Mowery Clinic)

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Mowery Clinic, LLC
COVID-19
V
ACCINE DOCUMENTATION / CONSENT FORM
VACCINE CONSENT:
I have been given a copy and have read, or have had explained to me, the information in the FACT SHEET FOR
RECIPIENTS AND CAREGIVERS EMERGENCY USE AUTHORIZATION (EUA) regarding the vaccine checked below. I ask that the
vaccine(s) checked below be given to me or to the person named below for whom I am authorized to make this request and authorize the
release of immunization records for the patient below to any school, health department or other healthcare provider. I consent to inclusion
of this immunization data in the Kansas Immunization Registry for myself or on behalf of the person named below.
By signing below you agree to all information provided in the first four sections of this form.
□ Moderna COVID-19 Vaccine
Signature of Patient/Patient Representative
Date
Relationship to Patient:
Self Parent
Guardian
Spouse
IMMUNIZATION SCREENING QUESTIONAIRE
1.
Are you feeling sick today?
Yes
No
2.
Have you ever received a dose of COVID-19 Vaccine?
If yes, which product?
□ Pfizer
□ Moderna
□ Other Product __________________________
_
Yes
No
3.
Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something? For example, a reaction for which you were
treated with epinephrine or EpiPen®, or for which you had to go to the hospital?
Yes
No
4.
Was the severe allergic reaction after receiving a COVID-19 vaccine?
Yes
No
5.
Was the severe allergic reaction after receiving another vaccine or another injectable medication?
Yes
No
6.
Do you have a bleeding disorder or are you taking a blood thinner?
Yes
No
7.
Have you received passive antibody therapy as treatment for COVID-19?
Yes
No
8.
Have you received any other vaccines in the past 14 days? (Influenza, MMR, etc)
Yes
No
PATIENT INFORMATION
Last Name:
First Name:
Birth Date: Gender: Female Male
Street Address
:
City:
Last Name:
First Name:
Birth Date:
Street Address:
City:
Phone:
VACCINE MVX CVX LOT # EXP DATE DOSE
Moderna, COVID-19 Vaccine, 100mcg/0.5mL MOD 207 1
st
Dose 2
nd
Dose
DATE TIME EXT SITE ROUTE
PATIENT LABEL
Right
Left
Deltoid (Preferred)
Vastus Lateralis
Intramuscular
(IM)
Signature & Title of Vaccine Administrator
Date
County:
County:
State:
Zip Code:
State:
Zip Code:
Phone:
PARENT/GUARANTOR INFORMATION (Required if patient is under 18 or patient is not guarantor)
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Moderna COVID-19 Vaccine (Mowery Clinic)

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Completed 16 August 2021

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