Moderna Covid-19 Vaccine
COVID-19 VACCINE INFORMATION AND CONSENT FORM
I have been given a copy and have read the Emergency Use Authorization (EUA) and reviewed the FDA Fact Sheet for Recipients
and Caregivers (https://www.modernatx.com/covid19vaccine-eua/eua-fact-sheet-recipients.pdf) prior to receiving the COVID-19
vaccine. I have had the chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of the
vaccine indicated and ask that it be given to me or the person named for whom I am authorized to make this request.
My signature acknowledges that I was advised to remain on site for 15 minutes after receiving the vaccine.
Those with previous anaphylactic reactions should stay for 30 minutes.
__________________ ______________________________________ X_________________________________________
Date Print Name Patient or Parent/Guardian Signature
FOR ADMINISTRATIVE USE ONLY
Name of Vaccine Administrator
_____ml 1
st
_____ml 2
nd
IM - L Arm
IM - R Arm
Date of Birth:
______/______/_________
EMERGENCY CONTACT: Name Relation Phone Number
Race: (check only 1)
Asian/Polynesian Black
Multiracial Native Am/Alaskan
White Unknown
Ethnicity: (check only 1)
Not Hispanic
Hispanic Unknown
Primary Language:
English
Other ___________
Please answer the health questions below:
1. Are you feeling sick today?
2. Have you ever received a dose of COVID-19 vaccine?
*If yes, which vaccine product and the date administered:
Pfizer _______________________________________
Moderna _____________________________________
Another Product _______________________________
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?
*Was the severe reaction after receiving a COVID-19 vaccine?
*Was the severe reaction after receiving another vaccine or another injectable medication?
4. Have you received another vaccine in the last 14 days?
5. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum)
as treatment for COVID-19?
6. Do you have a weakened immune system caused by something such as HIV infection or
cancer or do you take immunosuppressive drugs or therapies?
7. Do you have a bleeding disorder or are you taking a blood thinner?
8. Are you pregnant or breastfeeding?
