Demographics
First Name
Last Name
Sex
Choose...
Male
Female
Date of Birth
Race/ Ethnicity
Choose...
White
Black/African American
Asian
Hispanic
Native American
Pacific Islander
Other
Cell Number
Email Address
Address 1
Address 2
Country
State
Choose...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
City
Zip
Emergency Contact
Emergency Contact Telephone
Primary Physician
Primary Physician Telephone
Primary Insurance Name
AARP- Medicare Supplement
Aetna
AHF MCO of Florida, Inc
Alexander Nininger State Veterans Nursing Home
AMA Insurance Agency
American Republic Insurance Company
Amerigroup Community Care
AMICUS
AvMed Healthplan
Bankers United Life
BCBS New Jersey
BCBS North Carolina
BCBS of Florida
BCBS of Illinois
BCBS of Michigan
Better Health of Florida
CarePlus Health Plans
CATHOLICS HEALTH SYSTEMS
CIGNA
Coastal Administrative Services
Colonial Penn Life
Continental General Insurance Company
CoreSource MD PA IL IA
Coventry Healthcare
Department of Veterans Affairs
Emblem - Group Health (GHI) PPO
Empire NY Medicare Part B-PAYERID REQD
First Health (PayerID 25133) (Coventry)
GHI Group Health, Inc Claims
Golden Glades
Health Options - Florida Blue
Healthsun Health Plans
Highmark Senior Health Company Pennsylvania
Horizon BCBS of New Jersey
Humana
Magellan Health Services
Medica Health Care Plan
Medicaid Florida
Medicare Florida
Meritain Health/Agency Services
Molina Healthcare of Florida
National Association of Letter Carriers
NATIONAL FOUNDATION LIFE INS
Preferred Care Partners
Prestige Health Choice
Private Pay
SELF_PAY
Seminole Tribe of Florida CMG
Simply Health Care Plan
State Farm Insurance Companies
Sunshine State Health Plan (Ambetter) - Medical
Sunshine State Health Plan Medicaid
Transamerica Life Insurance
Tricare Reserve Select
TRICARE Wisconsin (NORTH-Health Net Federal)
UMR-Harrington
UNICARE
United American Ins Company
United HealthCare
UnitedHealthcare
USAA
Veterans Administration Patient Centered Community
Wellcare of Florida
WPS Commercial (HCFA Only)
Zelis
Primary Insurance Policy Number
Primary Insurance Group Number
Secondary Insurance Name
AARP- Medicare Supplement
Aetna
AHF MCO of Florida, Inc
Alexander Nininger State Veterans Nursing Home
AMA Insurance Agency
American Republic Insurance Company
Amerigroup Community Care
AMICUS
AvMed Healthplan
Bankers United Life
BCBS New Jersey
BCBS North Carolina
BCBS of Florida
BCBS of Illinois
BCBS of Michigan
Better Health of Florida
CarePlus Health Plans
CATHOLICS HEALTH SYSTEMS
CIGNA
Coastal Administrative Services
Colonial Penn Life
Continental General Insurance Company
CoreSource MD PA IL IA
Coventry Healthcare
Department of Veterans Affairs
Emblem - Group Health (GHI) PPO
Empire NY Medicare Part B-PAYERID REQD
First Health (PayerID 25133) (Coventry)
GHI Group Health, Inc Claims
Golden Glades
Health Options - Florida Blue
Healthsun Health Plans
Highmark Senior Health Company Pennsylvania
Horizon BCBS of New Jersey
Humana
Magellan Health Services
Medica Health Care Plan
Medicaid Florida
Medicare Florida
Meritain Health/Agency Services
Molina Healthcare of Florida
National Association of Letter Carriers
NATIONAL FOUNDATION LIFE INS
Preferred Care Partners
Prestige Health Choice
Private Pay
SELF_PAY
Seminole Tribe of Florida CMG
Simply Health Care Plan
State Farm Insurance Companies
Sunshine State Health Plan (Ambetter) - Medical
Sunshine State Health Plan Medicaid
Transamerica Life Insurance
Tricare Reserve Select
TRICARE Wisconsin (NORTH-Health Net Federal)
UMR-Harrington
UNICARE
United American Ins Company
United HealthCare
UnitedHealthcare
USAA
Veterans Administration Patient Centered Community
Wellcare of Florida
WPS Commercial (HCFA Only)
Zelis
Secondary Insurance Policy Number
Secondary Insurance Group Number
Screening
Are you sick today or have you had an illness in the last 30 days or a COVID diagnosis in the last 90 days or have you received convalescent plasma?
Yes
No
Do you have allergies to medications, food, a vaccine component, or latex?
Yes
No
Have you ever had a serious reaction after receiving a vaccination?
Yes
No
Do you have a long-term health problem with anemia, low platelets or other blood disorder, or have you had a problem with an IM injection?
Yes
No
Do you have cancer, leukemia, AIDS, or any other immune system disorder?
Yes
No
Do you take cortisone, prednisone, other steroids, or anticancer drugs, or have you had radiation treatments?
Yes
No
Have you had Guillain Barre Syndrome?
Yes
No
For women: Are you pregnant/breastfeeding or is there a chance you could become pregnant during the next 3 months?
Yes
No
Have you received any vaccinations in the past 4 weeks?
Yes
No
Risk Factors
Do you have any of the below conditions?
Diabetes mellitus
Yes
No
Hypertension or high blood pressure
Yes
No
Obesity (body mass index [BMI] of 30 kg/m2 or higher
Yes
No
Pregnancy
Yes
No
Cancer
Yes
No
Chronic kidney disease
Yes
No
COPD (chronic obstructive pulmonary disease) or Asthma (moderate-to-severe)
Yes
No
Cystic fibrosis
Yes
No
Pulmonary fibrosis (having damaged or scarred lung tissues)
Yes
No
Smoking
Yes
No
Any Heart conditions
Yes
No
Cerebrovascular disease
Yes
No
Neurologic conditions, such as dementia )
Yes
No
Down Syndrome
Yes
No
Weakened Immune System
Yes
No
Liver disease
Yes
No
Any Blood Disorders
Yes
No
Sickle cell disease
Yes
No
Have you been Hospitalized in the last 12 Months?
Yes
No
If yes, How many Times?
Consent
I understand that I am not required to receive the Vaccine; however, I have voluntarily chosen to receive the Vaccine and accept all known and potential risks related to receiving the Vaccine.
I have been provided with a copy of, and reviewed the contents of, the attached Vaccine Information Sheet (VIS) or Emergency Use Authorization (EUA)
The undersigned Provider Representative has explained to me, and I understand that
Known potential adverse reactions to the Vaccine include each of the potential adverse reactions identified in the VIS or EUA provided to me.
There may be additional adverse reactions to the Vaccine that are not identified in the VIS or EUA provided to me.
I have had the opportunity to ask questions concerning the Vaccine, the administration of the Vaccine and potential adverse health consequences of receiving the Vaccine, and all of my questions have been answered to my satisfaction.
I understand that my failure to provide full and accurate information regarding my health status may result in adverse health consequences to me, including without limitation
I have provided full and truthful information for the completion of this Consent Form