COVID-19 Vaccine Screening and Agreement

STOP Please only fill out this form if you have an appointment

Information collected on this form will be used to document that you have received vaccine(s). Information about your vaccine(s) may be shared through the Minnesota Immunization Information Connection (MIIC) with other health care providers, schools, health departments, and others authorized under law to receive it. If you have any questions, please ask your doctor or other health care provider. If you have questions about MIIC, refer to MIIC and the Public (www.health.state.mn.us/people/immunize/miic/public.html) or call 1-800-657-3970.

Assignment of benefits and responsibilities for payment

This lets us bill your health plan or company and to receive payment directly. There is no cost for the COVID-19 vaccine, Although we will bill your insurance company for an administrative fee.

I authorize this health provider to bill my health plan or other payers on my behalf, and to receive payment of authorized benefits.

Contact information – person being vaccinated

Patient’s name:

Last Name:

First Name:

Middle Name:

Date of birth:

Primary phone number:

Address:

(Street or P.O. Box):

City:

State:

Zip Code:

Parent’s name: (if younger that 18 years old)

Payment information Bring a copy of your insurance card with you!

Primary insurance carrier:

Policy/ID/member number:

Group number:

Secondary insurance carrier:

Policy/ID/member number:

Group number:

Policy holder, if different from the person getting vaccinated:

Name:

Date of birth:

Check here if person getting the vaccine does not have insurance.

Agreement

By signing below, I understand, recognize, approve, and agree that:

I have received and read or had explained to me the Emergency Use Authorization Fact Sheet for the following COVID-19 vaccine: [Insert name of vaccine product below].
I have had the chance to ask questions which were answered to my satisfaction, and I understand the benefits and risks of the COVID-19 vaccine as described.
I agree to receive the COVID-19 vaccine for myself or for the person named above.

Name of Vaccine:

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of patient or parent/guardian:

Date:

Health history

Do you want to receive a COVID-19 vaccine today?

Yes No

Are you the correct age to receive the COVID-19 vaccine?

Pfizer-BioNTech vaccine: You must be 12 years or older.

Yes No

Moderna vaccine: You must be 18 years or older

Yes No

Have you been diagnosed with COVID-19 infection in the past 90 days?

Yes No Unknown

Are you feeling sick today?

Yes No Unknown

Have you received any other vaccines (that were not COVID-19 vaccine) within the past 14 days?

Yes No Unknown

Have you had a known exposure to someone with COVID-19 in the past 14 days?

Yes No Unknown

Are you pregnant?

Yes No Not Applicable

Have you ever received a dose of COVID-19 vaccine?

Yes No Not Applicable

If yes, list vaccine product and date received:

Did you have a severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a component of the COVID-19 vaccine?

Yes No Unknown

Immediate allergic reaction (within 4 hours) of any severity to a previous COVID-19 vaccine dose or known (diagnosed) allergy to a component of the vaccine or any of its ingredients (including polyethylene glycol [PEG] or polysorbate)?

Yes No Unknown

Did you have a delayed allergic reaction at the injection site (e.g., redness, itching) after a first dose of COVID-19 vaccine?

Yes No Not Applicable

Immediate allergic reaction to any other vaccine or injectable therapy (e.g., shots in the muscle (intramuscular), in the vein (intravenous), or into the fatty tissue (subcutaneous)? Does not include allergy shots.

Yes No Unknown

Received monoclonal antibodies or convalescent plasma as part of COVID-19 treatment in the past 90 days?

Yes No Unknown

PATIENT/PARENT DO NOT WRITE BELOW THIS LINE

Providers ONLY

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