Pfizer COVID-19 Vaccine Screening Form & Consent

Please correct the errors described below.

Patient's Name

Patient’s Date of Birth

Please answer the following questions about your child (or yourself if you are the one receiving the COVID-19 vaccine). If you answer “yes” to any questions, it does not necessarily mean you should not be vaccinated.

Has your child ever received a COVID-19 vaccination?

Yes No

Does your child feel sick today or have a fever?

Yes No

Has your child ever had a SEVERE reaction to any vaccine?

Yes No

If yes, please explain.

Has your child ever had an anaphylactic reaction?

Yes No

Has your child ever had a reaction to latex?

Yes No

Does your child have a blood clotting disorder and/or take anticoagulant medication(s) which may result in increased bleeding?

Yes No

Has your child ever had a positive test for COVID-19 or been told they had COVID-19?

Yes No

If yes, when?

I have read the Omaha Children's Clinic Pfizer COVID-19 Vaccine Handout and have been provided with the most current EAU Pfizer Vaccine Fact Sheet and have had a chance to ask questions which were answered to my satisfaction. I understand the benefits and risks of the COVID-19 vaccine, including side effects and request the vaccine be given to me or my child.

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.

Signed

Date

Relationship if patient under 19 years

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