COVID Vaccine Consent Form

_______________________________ ___________________________ __________________________ ___________

_________________________ ___________________________

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_______________________ __________________________________ ___________________________________

_____________________________________________ _________________________________________________ Race: White Black/African American Asian Native Hawaiian/Pacific Islander American Indian/Alaskan Native

Other Hispanic: Y N

By Signing and initialing below, I confirm have received information regarding the following COVID-19 Vaccination:

First Name Middle Name Last Name Suffix

Date of Birth SS# Gender: M F

Address

County Phone Number Email

Mother’s First Name Mother’s Maiden Name

I have received the FDA Fact Sheet for Patients and Parents/Caregivers,

which includes information on potential risks, benefits, purpose, side effects,

dosing methods, and alternative treatment choices for the Vaccine.

I have been informed that the Vaccine is an unapproved vaccine that may

prevent COVID-19. There is no FDA-approved vaccine to prevent COVID-

19 but the Vaccine has received Emergency Use Authorization (EAU) from

the FDA.

Initials:

I hereby give my consent to the Abilene-Taylor County Public Health District (ATCPHD) to administer the Vaccine I have requested

above. I understand the risk and benefits associated with the Vaccine being administered and have received, read and/or had explained

to me the written information on the Vaccine I have elected to receive. I have had the opportunity to ask questions that were answered

to my satisfaction. As with all medical treatment, there is no guarantee that I will not experience an adverse reaction from the

Vaccine. I understand that the information contained on this form may be shared with the state or federal immunization registries and

will remain confidential and will not be released except as permitted or required by law. I have read and understood the HIPAA form

explaining my privacy rights, ATCPHD’s duty to protect health information that identifies you and how ATCPHD may use or

disclose health information that identifies you without your written permission. I hereby acknowledge receipt of the ATCPHD’s

“Notice of Privacy Practices” form. Furthermore, I agree to remain for approximate 15-30 minutes after administration for

observation.

Signature: ___________________________________________________ Date: _______________________

Printed Name: ________________________________________________

Initials:

Street City State Zip

PLEASE PRINT

For Provider Use Only

1st Dose / 2nd Dose

Insured / Uninsured

For vaccine recipients: The following questions will help us determine if there is any

reason you should not get the COVID-19 vaccine today. If you

answer “yes” to any question, it does not necessarily mean you

should not be vaccinated. It just means additional questions

may be asked. If a question is not clear, please ask your

healthcare provider to explain it.

Patient Name: _______________________________

Age: _________________ DOB: ______________

1. Are you feeling sick today?

2. Have you ever received a dose of COVID-19 vaccine?

If yes, which vaccine 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 allergic reaction after receiving a COVID-19 vaccine?

Was the severe allergic reaction after receiving another vaccine or

another injectable medication?

4. Do you have a bleeding disorder or are you taking a blood thinner?

5. Have you received passive antibody therapy as treatment for COVID-19?

6. Are you pregnant or lactating?

Client Signature: __________________________________________________ Date: ______________________

Clinical Use Only: Vaccine Provided: IM Nasal ID Location: (R) (L) (Deltoid) (VL) Clinical Site: _____________________________________________

Vaccinator’s Signature: _________________________________________ Date: _________________________

ATCPHD Pre-Vaccination Form for COVID-19

Yes No Don’t Know

Abilene-Taylor County Public Health District

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