Informed Consent to Receive Vaccines
The following questions will help us determine which vaccines you may be given today. If you answer "yes" to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions must be asked. If a question is not clear, please ask your healthcare provider.
TIME TO COMPLETE:
REQUIRED DOCUMENTS:Please have your insurance card ready to upload
- Complete All sections of the consent form
- Answer all the questions
- Submit one form for each patient
Are you sick today?
Have you had any of the following symptoms in the past 14 days: Cough, muscle pain, fever (temp > 100.4F), unexpected shortness of breath, chills, or sore throat, loss of taste/odor?
Have you been in contact with anyone with confirmed or suspected Coronavirus (COVID-19) infection within the past 14 days?
Do you have allergies to medications, foods or any vaccine? (i.e. gelatin, eggs, latex, etc.)
Have you ever had a serious reaction after receiving a vaccination?
Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g., diabetes), anemia or other blood disorder?
For patients between the ages of 2 and 4 years: has a healthcare provider told you that the child had wheezing or asthma in the past 12 months?
If the patient is a baby: have you ever been told he or she has had intussusceptions?
Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?
In the past 3 months, have you taken medications that weaken your immune system, such as cortisone, prednisone, other steroids, or anticancer drugs, home infusions, weekly injections (i.e. Humira, Enbrel, or Xeljanz), or have you had radiation treatments?
Have you, a sibling, or parent had a seizure or a brain or other nervous system problem? (i.e. Guillain-Barre Syndrome, encephalopathy)
During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?
For women: Are you pregnant or is there a chance you could become pregnant during the next month?
Have you received any vaccinations or skin tests in the past 4 weeks?
Are you currently on anticoagulant/antiplatelet medications? (Warfarin, aspirin, Plavix, Lovenox, etc.)
Are you current on all your vaccinations? (Pneumonia, Shingles, TdaP, etc.)