COVID-19 Vaccine Consent Form Header Image

COVID-19 Vaccine Consent Form

Pfizer-BIONTECH'S COVID-19 vaccine is for people 12  years and older. Moderna COVID-19 is for people 18 years and older.

Name*
Date Of Birth*

Contact Information

Address*
For example: frontline healthcare worker, critical infrastructure oil and gas, critical infrastructure mining, response team member, etc.
Please select which COVID-19 vaccine dose?*
  • Cancer
  • Chronic Kidney Disease
  • Heart Conditions, such as heart failure, coronary artery disease, or cardiomyopathies
  • Immunocompromised state (weakened immune system) from solid organ transplant
  • Obesity (body mass index (BMI) of 30kg/m2 or higher but <40kg/m2)
  • Severe Obesity (BMI > = 40kg/m2)
  • Pregnancy
  • Sickle Cell Disease
  • Smoking
  • Type 2 Diabetes
Do you have any of the above listed chronic health conditions?*
Have you previously received a COVID-19 vaccine?*
Have you had a severe allergic reaction (e.g., anaphylaxis) after receiving COVID-19 vaccine? *
Have you had a severe allergic reaction (e.g., anaphylaxis) to another vaccine (not including Pfizer-BioNTech Vaccine) or any other injectable medication?*
Do you have a bleeding disorder or are you taking a blood thinner?*
Are you immunocompromised (have a weakened immune system such as cancer, leukemia, HIV/AIDS, or any other immune system problem) or are you taking medication that affects your immune system? *
Do you have a fever?*
Are you feeling sick?*
Are you pregnant?*
Could you become pregnant in the next several weeks?*
Are you breastfeeding (nursing)?*

IMPORTANT 

If you receive Pfizer-BIONTECH's vaccine, you should receive a second vaccination three weeks (21 days) later.

If you receive Moderna's vaccine, you should receive a second vaccination four weeks (28 days) later. 

Please select the desired vaccine.*

CONSENT FOR VACCINATION(S) - YOU MUST SIGN HERE FOR YOU/YOUR FAMILY TO BE VACCINATED

Health care services are confidential. No information is released without your consent except as may be required under public health and safety laws. Information used for evaluation and planning purposes never includes personal identifiers. To access a copy of Beacon's notice of privacy practices please request from Beacon by sending email to info@beaconohss.com.

By Completing this form, I am acknowledging: 

  • The information provided is correct
  • I have read the EUA fact sheet provided 
  • I understand the risks and benefits of getting the vaccine(s) and consent for me and my family to be vaccinated 
  • Any questions I had about the vaccine(s) have been answered 
Use your mouse or finger to draw your signature above