COVID-19 VACCINE CONSENT FORMSection 1: Information about the patient to receive the Pfizer COVID-19 Vaccine:Name(Required) First Last Age(Required)Date of Birth(Required) MM slash DD slash YYYY Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent/Guardian's Name(if under 18 years old) First Last Phone(Required)Name of Primary Care Provider Section 2: Information about the Pfizer vaccinePatient is being offered a COVID-19 vaccine made by Pfizer-BioNTech. The PfizerBioNTech COVID-19 Vaccine is approved by the U.S. Food and Drug Administration (FDA) for people over 16 years old, with the brand name Comirnaty®. The FDA has also issued an Emergency Use Authorization for Pfizer-BioNTech COVID-19 Vaccine for people ages 5 and older (see below for more information). Both the Pfizer-BioNTech COVID-19 Vaccine and Comirnaty® are administered as a 2-dose series, 3 weeks apart, into the muscle.The vaccine may not protect everyone from COVID-19 disease. Some people may experience side effects after getting the vaccine. Side effects that have been reported include injection site pain, tiredness, headache, muscle pain, chills, joint pain, fever, injection site swelling, injection site redness, nausea, feeling unwell, and swollen lymph nodes. There is a remote chance that the vaccine could cause a severe allergic reaction. A severe allergic reaction would usually occur within a few minutes to one hour after getting a dose of the vaccine. For this reason, a vaccination provider may ask the person receiving the vaccine to stay at the place where they received their vaccine for monitoring after vaccination. Signs of a severe allergic reaction can include difficulty breathing, swelling of the face and throat, a fast heartbeat, and/or a bad rash all over the body.Additional information is available in the Pfizer-BioNTech COVID-19 Vaccine “Fact Sheet for Recipients and Caregivers” available at: 5-11 Years of Age (https://www.fda.gov/media/153717/download) 12+ Years of Age (https://www.fda.gov/media/153716/download) Emergency Use Authorization The FDA has made the COVID-19 vaccine available under an emergency use authorization (EUA). The EUA is used when circumstances exist to justify the emergency use of drugs and biological products during an emergency, such as the COVID-19 pandemic. This vaccine has not undergone the same type of review as an FDA-approved or cleared product. However, the FDA’s decision to make the vaccine available is based on the totality of scientific evidence available, showing that known and potential benefits of the vaccine outweigh the known and potential risks. Please note: FDA approved the Pfizer-BioNTech COVID-19 vaccine as a two-dose series in individuals 16 years of age and older. The vaccine continues to be available under an EUA for certain populations, including for those individuals 5 through 15 years of age. Section 3: Screening QuestionnaireThe vaccine provider will need certain information about your medical history before administering the vaccine.1. Has the patient received a COVID-19 vaccine?(Required)(Moderna, Pfizer or Johnson and Johnson) Yes No Number of doses(Required) One Two Date of first dose(Required) MM slash DD slash YYYY Date of second dose(Required) MM slash DD slash YYYY 2. Has the patient been treated with antibody therapy or convalescent plasma for COVID-19 in the past 90 days (3 months)(Required) Yes No Date of last dose(Required) MM slash DD slash YYYY 3. Has the patient ever had an immediate allergic reaction (ex. Hives, facial swelling, difficulty breathing, anaphylaxis) to any vaccine, injection, or shot or to any component of the COVID-19 vaccine, or a severe allergic reaction (anaphylaxis) to anything?(Required) Yes No 4. Does the patient have cancer, leukemia, HIV/AIDs, or any other condition that weakens the immune system?(Required) Yes No 5. Does the patient take any medications that affect the immune system, such as cortisone, prednisone or other steroids, anticancer drugs, or have they had any radiation treatments?(Required) Yes No 6. Does the patient have a bleeding disorder, a history of blood clots, or are they taking a blood thinner?(Required) Yes No 7. Does the patient 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 or extra precautions may be taken by the provider for your child’s appointment (ex. 30 minute post-administration monitoring in individuals with a history of anaphylaxis vs. 15 minutes). Section 4: ConsentCONSENT FOR VACCINATION: I have reviewed the information about the PfizerBioNTech and Comirnaty® COVID-19 Vaccines in Section 2 above and understand the risks and benefits. In providing my consent below, I agree that: I have reviewed this consent form, and I understand that the “Fact Sheet for Recipients and Caregivers,” includes more detailed information about the potential risks and benefits of the Pfizer-BioNTech and Comirnaty® COVID-19 Vaccines. I have the legal authority to consent to have the patient named above vaccinated with the Pfizer-BioNTech or Comirnaty® COVID-19 Vaccine. If I have health insurance that covers the patient named above, I give permission for my insurance company to be billed for the costs of administering the Pfizer Comirnaty® COVID-19 Vaccine. The government is paying for the Pfizer Comirnaty® COVID-19 Vaccine itself, and I will not be billed for that portion of the cost of my immunization. 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 through https://portal.ct.gov/DPH/Immunizations/ALL-ABOUT-CT-WiZ. I GIVE CONSENT for the patient named at the top of this form to get vaccinated with the Pfizer-BioNTech or Comirnaty® 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 vaccine will not be administered.Signature(Required) Date of signature(Required) MM slash DD slash YYYY Relationship to patient if under 18 / Representative
