COVID-19 Vaccine Informed Consent Form
Personal Information
Full Name:
Date of Birth:
Address:
Phone:
Email:
Pre-Vaccination Questions
1. Are you feeling sick today?
Yes
No
2. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to a vaccine or injectable medication?
Yes
No
3. Do you have any allergies?
Yes
No
If yes, please list:
4. Have you tested positive for COVID-19 in the past 14 days?
Yes
No
5. Are you currently pregnant, planning to become pregnant, or breastfeeding?
Yes
No
Consent
I have read or had explained to me the information about the COVID-19 vaccine. I have had a chance to ask questions and they were answered to my satisfaction. I consent to receive the COVID-19 vaccination.
Signature:
Date: