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COVID-19 Vaccine Consent Form
Click here to review the COVID-19 Vaccine Consent Form
Section 1: Information about the Client
Client's Name
(Required)
First
Last
Date of Birth
(Required)
MM slash DD slash YYYY
Client Age
(Required)
Please enter a number from
0
to
100
.
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
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
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Primary Care Provider
(Required)
Client is
(Required)
Self
Child
Client (check one)
(Required)
has Private Insurance
has Husky/Medicaid
has no insurance
is Native American or Alaskan Native
Parent/Guardian's Name (If under 18 years of age)
First
Last
Phone
(Required)
School Child Attends (if applicable)
Grade/Teacher
Section 2: Screening Questionnaire
1. Has the client had a COVID-19 vaccine?
(Required)
Yes
No
If you selected yes..
Date
MM slash DD slash YYYY
Brand/Manufacturer
Date
MM slash DD slash YYYY
Brand/Manufacturer
Date
MM slash DD slash YYYY
Brand/Manufacturer
Date
MM slash DD slash YYYY
Brand/Manufacturer
Date
MM slash DD slash YYYY
Brand/Manufacturer
2. Has the client ever had COVID-19 and been treated with antibody therapy or convalescent plasma?
(Required)
Yes
No
If you selected yes..
(Required)
Date of Last Dose
MM slash DD slash YYYY
3. Is there anyone in the client's household who has a poor immune system?
(Required)
Yes
No
4. Has the client ever had an allergic reaction to: A component of a COVID-19 vaccine, including either of the following: Polyethylene glycol (PEG), which is found in some medications such as laxatives and preps for colonoscopy procedures, Polysorbate, which is found in some vaccines, film coated tablets, or intravenous steroids, A previous dose of COVID-19 vaccine, A vaccine or injectable therapy that contains multiple components, one of which is a COVID-19 component, but it is not known which component elicited the immediate reaction, Another vaccine (other than COVID-19 vaccine) or an injectable medication?
(Required)
Yes
No
5. Has the client ever had a severe allergic reaction (such as anaphylaxis) to something other than a vaccine or injectable medication? This would include food, pet, venom, environmental, or oral medication allergies.
(Required)
Yes
No
6. Does the client take any medications or have any medical conditions that affect the immune system?
(Required)
Yes
No
7. Does the client have a history of myocarditis (inflammation of the heart muscle) or pericarditis (inflammation of the lining around the heart)?
(Required)
Yes
No
Please note, if you answered “yes” to any of the above questions, your appointment may be rescheduled, a third dose may be recommended as part of the primary series, or extra precautions may be taken by the provider during the appointment, such as a 30 minute wait time following vaccine administration in a patient with a history of anaphylaxis.
Section 3: Consent
Acknowledgement:
I have been provided an opportunity to review the COVID-19 Vaccine Fact Sheet for Recipients and Caregivers. I understand that I can review the Fact Sheet onsite or online.
Please select the link below to review the COVID-19 Vaccine “Fact Sheet for Recipients and Caregivers”:
(6 months through 11 years) (
https://www.fda.gov/media/167209/download
)
(12 years and older) (
https://www.fda.gov/media/144638/download
)
CONSENT FOR VACCINATION:
In providing my consent below, I agree that:
I have read or had explained to me the information contained in the Emergency Use Authorization Fact Sheet for Recipients and Caregivers for the COVID-19 vaccine and understand the risks and benefits of the vaccine. I have had a chance to ask questions which have been answered to my satisfaction I understand the benefits and risks of the vaccine.
I understand that the COVID-19 vaccine is a voluntary vaccine currently being given under the Emergency Use Authorization status and I have the legal authority to consent to have the client named above vaccinated with the COVID-19 vaccine if signing for someone other than myself.
If I have health insurance that covers the client named above, I give permission for my insurance company to be billed for the costs of administering the COVID-19 vaccine.
I understand that as required by state law, all immunizations will be reported to the Department of Public Health Connecticut Immunization Information System (CT WIZ). I can access the more information at
https://portal.ct.gov/DPH/Immunizations/ALL-ABOUT-CT-WiZ
.
In the event of an emergency situation, emergency medication (Epinephrine/Benadryl) may be administered to the client. In the event of an emergency situation of a minor in which a legal guardian is not present, I authorize Child and Family Agency staff or designee to obtain any necessary medical care they deem necessary including, but not limited to, obtaining paramedic assistance and transport to a local hospital for additional treatment or observation.
I GIVE CONSENT for the client named at the top of this form to get vaccinated with the COVID-19 Vaccine and have reviewed and agree to the information included in Section 3 of this form. (If this consent is not signed, dated, and returned, the client will not be vaccinated.)
Signature
(Required)
Relationship to client (if <18 years of age)
Date of signature
(Required)
MM slash DD slash YYYY
