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 SupplementAetnaAHF MCO of Florida, IncAlexander Nininger State Veterans Nursing HomeAMA Insurance AgencyAmerican Republic Insurance CompanyAmerigroup Community CareAMICUSAvMed HealthplanBankers United LifeBCBS New JerseyBCBS North CarolinaBCBS of FloridaBCBS of IllinoisBCBS of MichiganBetter Health of FloridaCarePlus Health PlansCATHOLICS HEALTH SYSTEMSCIGNA Coastal Administrative ServicesColonial Penn LifeContinental General Insurance CompanyCoreSource MD PA IL IACoventry HealthcareDepartment of Veterans AffairsEmblem - Group Health (GHI) PPOEmpire NY Medicare Part B-PAYERID REQDFirst Health (PayerID 25133) (Coventry)GHI Group Health, Inc ClaimsGolden GladesHealth Options - Florida BlueHealthsun Health PlansHighmark Senior Health Company PennsylvaniaHorizon BCBS of New JerseyHumanaMagellan Health ServicesMedica Health Care PlanMedicaid FloridaMedicare FloridaMeritain Health/Agency ServicesMolina Healthcare of FloridaNational Association of Letter CarriersNATIONAL FOUNDATION LIFE INSPreferred Care PartnersPrestige Health ChoicePrivate PaySELF_PAYSeminole Tribe of Florida CMGSimply Health Care PlanState Farm Insurance CompaniesSunshine State Health Plan (Ambetter) - MedicalSunshine State Health Plan MedicaidTransamerica Life InsuranceTricare Reserve Select TRICARE Wisconsin (NORTH-Health Net Federal)UMR-HarringtonUNICAREUnited American Ins CompanyUnited HealthCareUnitedHealthcareUSAAVeterans Administration Patient Centered CommunityWellcare of FloridaWPS Commercial (HCFA Only)Zelis

Primary Insurance Policy Number

Primary Insurance Group Number

Secondary Insurance Name AARP- Medicare SupplementAetnaAHF MCO of Florida, IncAlexander Nininger State Veterans Nursing HomeAMA Insurance AgencyAmerican Republic Insurance CompanyAmerigroup Community CareAMICUSAvMed HealthplanBankers United LifeBCBS New JerseyBCBS North CarolinaBCBS of FloridaBCBS of IllinoisBCBS of MichiganBetter Health of FloridaCarePlus Health PlansCATHOLICS HEALTH SYSTEMSCIGNA Coastal Administrative ServicesColonial Penn LifeContinental General Insurance CompanyCoreSource MD PA IL IACoventry HealthcareDepartment of Veterans AffairsEmblem - Group Health (GHI) PPOEmpire NY Medicare Part B-PAYERID REQDFirst Health (PayerID 25133) (Coventry)GHI Group Health, Inc ClaimsGolden GladesHealth Options - Florida BlueHealthsun Health PlansHighmark Senior Health Company PennsylvaniaHorizon BCBS of New JerseyHumanaMagellan Health ServicesMedica Health Care PlanMedicaid FloridaMedicare FloridaMeritain Health/Agency ServicesMolina Healthcare of FloridaNational Association of Letter CarriersNATIONAL FOUNDATION LIFE INSPreferred Care PartnersPrestige Health ChoicePrivate PaySELF_PAYSeminole Tribe of Florida CMGSimply Health Care PlanState Farm Insurance CompaniesSunshine State Health Plan (Ambetter) - MedicalSunshine State Health Plan MedicaidTransamerica Life InsuranceTricare Reserve Select TRICARE Wisconsin (NORTH-Health Net Federal)UMR-HarringtonUNICAREUnited American Ins CompanyUnited HealthCareUnitedHealthcareUSAAVeterans Administration Patient Centered CommunityWellcare of FloridaWPS 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