COVID-19 Vaccine Consent Form

Gather informed consent from patients before administering the COVID-19 vaccine, including relevant medical history and emergency contact details.

Use this template

Vaccine Manufacturer

Do you have any of the following symptoms? (select all that apply)

Do you have any immunocompromising conditions? (select all that apply)

HIV/AIDS Active cancer treatment Organ transplant Autoimmune disorder None of the above

Have you ever tested positive for COVID-19?

Yes No

Test Date

In the last 14 days, have you been in contact with someone confirmed to have COVID-19?

Yes No

In the last 14 days, have you traveled internationally?

Yes No

Do you have any of the following conditions?

Allergy to vaccine components Severe allergic reaction to a previous dose Bleeding disorder Pregnant or breastfeeding None of the above

Name

First Name

Last Name

Email

Phone Number

Address

Street Address

City

State / Province

ZIP / Postal Code

Parent/Guardian Name

First Name

Last Name

Parent/Guardian Phone Number

Relationship

Printed Name

Date

Signature

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