Section 1: Information about the patient to receive the COVID-19 VaccinePatient Name(Required) First Last Patient Age(Required)Please enter a number from 0 to 100.Patient 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 Name of Primary Care Provider(Required) Parent/Guardian's Name (If under 18 years of age) First Last Phone(Required)School Child Attends Grade/Teacher Section 2: Screening QuestionnaireThe vaccine provider will need certain information about the patient’s medical history before administering the vaccine.1. Has the patient received a COVID-19 vaccine?(Required) Yes No Date MM slash DD slash YYYY Brand/Manufacturer Date MM slash DD slash YYYY Brand/Manufacturer Date MM slash DD slash YYYY Brand/Manufacturer Date MM slash DD slash YYYY Brand/Manufacturer Date MM slash DD slash YYYY Brand/Manufacturer 2. Has the patient ever had COVID-19 and been treated with antibody therapy or convalescent plasma?(Required) Yes No Date of last dose(Required) MM slash DD slash YYYY 3. Has the patient ever had an allergic reaction to: A component of a COVID-19 vaccine, including either of the following: Polyethylene glycol (PEG), which is found in some medications such as laxatives and preps for colonoscopy procedures, Polysorbate, which is found in some vaccines, film coated tablets, or intravenous steroids, A previous dose of COVID-19 vaccine, A vaccine or injectable therapy that contains multiple components, one of which is a COVID-19 component, but it is not known which component elicited the immediate reaction, Another vaccine (other than COVID-19 vaccine) or an injectable medication?(Required) Yes No 4. Has the patient ever had a severe allergic reaction (such as anaphylaxis) to something other than a vaccine or injectable medication? This would include food, pet, venom, environmental, or oral medication allergies.(Required) Yes No 5. Does the patient take any medications or have any medical conditions that affect the immune system?(Required) Yes No 6. 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, a third dose may be recommended as part of the primary series, or extra precautions may be taken by the provider during the appointment, such as a 30 minute wait time following vaccine administration in a patient with a history of anaphylaxis. Section 3: ConsentAcknowledgement: I have been provided an opportunity to review the COVID-19 Vaccine Fact Sheet for Recipients and Caregivers. I understand that I can review the Fact Sheet onsite or online.Please select the link below to review the COVID-19 Vaccine “Fact Sheet for Recipients and Caregivers”: 6 months-65+ Years of Age (Pfizer-BioNTech Bivalent Booster) ( https://www.fda.gov/media/167212/download) 6 months-65+ Years of Age (Moderna Bivalent Booster) (https://www.fda.gov/media/167209/download) CONSENT FOR VACCINATION: In providing my consent below, I agree that: I have read or had explained to me the information contained in the Emergency Use Authorization Fact Sheet for Recipients and Caregivers for the COVID-19 vaccine and understand the risks and benefits of the vaccine. I have had a chance to ask questions which have been answered to my satisfaction I understand the benefits and risks of the vaccine. I understand that the COVID-19 vaccine is a voluntary vaccine currently being given under the Emergency Use Authorization status and I have the legal authority to consent to have the patient named above vaccinated with the COVID-19 vaccine if signing for someone other than myself. 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 COVID-19 vaccine. The government is paying for 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 at https://portal.ct.gov/DPH/Immunizations/ALL-ABOUT-CT-WiZ. In the event of an emergency situation, emergency medication (Epinephrine/Benadryl) may be administered to the patient. In the event of an emergency situation of a minor in which a legal guardian is not present, I authorize Child and Family Agency staff or designee to obtain any necessary medical care they deem necessary including, but not limited to, obtaining paramedic assistance and transport to a local hospital for additional treatment or observation. I GIVE CONSENT for the patient named at the top of this form to get vaccinated with the 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 patient will not be vaccinated.)Signature(Required) Relationship to Patient (if <18 years of age) Date of signature(Required) MM slash DD slash YYYY
