COVID-19 Immunization Screening and Consent

Recipient Name

Preferred Name

Date of Birth

Legal Gender

Address

City

State

Zip

Email address

Parent/Guardian/ Surrogate (if applicable)

Phone

Preferred language

Clinic/Office Site Where Vaccine is Administered

Margolin, Keinarth and Alberda M.D. Family Health Clinic

Primary Care Physician Address/Phone Number

5222 Burnet Rd. Ste 200 Austin, Texas 78681 / 512-459-9889

Screening Questionnaire

If yes, when did you receive the last dose?

If yes, how long ago was your most recent vaccine?

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 completed the same type of review as an FDA-approved or cleared product. However, the FDA’s decision to make the vaccine available under an EUA is based on the existence of a public health emergency and the totality of scientific evidence available, showing that known and potential benefits of the vaccine outweigh the known and potential risks.

Consent

I have been provided and have read, or had explained to me, the information sheet about the COVID-19 vaccination. I understand that if this vaccine requires two doses, two doses of this vaccine will need to be administered (given) in order for it to be effective. I have been given an opportunity to ask questions which were answered to my satisfaction (and ensured the person named above for whom I am authorized to provide surrogate consent was also given a chance to ask questions). I understand the benefits and risks of the vaccination as described.

I request that the COVID-19 vaccination be given to me (or the person named above for whom I am authorized to make this request and provide surrogate consent). I understand there will be no cost to me for this vaccine. I understand that any monies or benefits for administering the vaccine will be assigned and transferred to the vaccinating provider, including benefits/monies from my health insurance plan, Medicare, Medicaid or other third parties who are financially responsible for my medical care. I authorize release of all information needed (including but not limited to medical records, copies of claims and itemized bills) to verify payment and as needed for other public health purposes, including reporting to applicable vaccine registries.

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

Recipient/Surrogate/Guardian (Signature)

Date

Relationship to patient, if other than recipient

Telephonic Interpreter’s ID #

Date

Signature: Interpreter

Date

Interpreter’s Name and Relationship to Patient

Area Below to be Completed by Vaccinator

Which vaccine is the patient receiving today?

EUA Fact Sheet Date

Manufacturer & Lot Number

Administration Site

Left Deltoid

Right Deltoid

Left Thigh

Right Thigh

Nasal

Dosage

0.5 ml

0.25ml

I have reviewed side effects with patient (and parent, guardian or surrogate, as applicable)

I confirm that the patient (and their surrogate, if applicable) was given an opportunity to ask questions about the vaccination, and all the questions asked by them (and/or their surrogate) have been answered correctly and to the best of my ability

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

Vaccinator Signature

Date

Your information will be encrypted.