COVID-19 Vaccine Screening and Administration Form
Please correct the errors described below.
Please print neatly in capital letters. Please answer all questions as completely as possible.
Please complete ALL the information below as accurately as possible. If you are completing this form for your minor child, do not use nick-names or abbreviations, except where allowed. All information will be kept confidential.
If under 18 years of age please complete.
If you have already been vaccinated with a COVID-19 vaccine, please tell us which vaccine(s) was received, the number of doses, and the date(s) of vaccination
Health Screening Questions
Authorization to Administer COVID-19 Vaccine
I have read or had explained to me the Emergency Use Authorization for the use of the COVID-19 vaccine and understand the benefits and risks to me or my child of receiving this vaccine. I have had a chance to ask questions, which were answered to my satisfaction. I hereby release this provider, its employees and its volunteers from any liability for any results which may occur from the administration of this vaccine.
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Highlands Integrative Pediatrics
ADDITIONAL DOSE INFORMATION
Currently, CDC is recommending that moderately to severely immunocompromised people receive an additional dose. Applies to: Pfizer vaccine - age 12 and over; Moderna vaccine - ages 18 and over at this time.Effective 8/13/2021 for those who have:
Been receiving active cancer treatment for tumors or cancers of the blood
Received an organ transplant and are taking medicine to suppress the immune system
Received a stem cell transplant within the last 2 years or are taking medicine to suppress the immune system
Moderate or severe primary immunodeficiency (such as DiGeorge syndrome, Wiskott-Aldrich syndrome)
Advanced or untreated HIV infection
Active treatment with high-dose corticosteroids or other drugs that may suppress immune response ((i.e., ≥20mg prednisone or equivalent per day), alkylating agents, antimetabolites, transplant-related immunosuppressive drugs, cancer chemotherapeutic agents classified as severely immunosuppressive, tumor-necrosis (TNF) blockers, and other biologic agents that are immunosuppressive or immunomodulatory).
The additional mRNA COVID-19 vaccine dose should be the same vaccine product as the initial 2-dose mRNA COVID-19 primary vaccine series (Pfizer-BioNTech or Moderna).
If the mRNA COVID-19 vaccine product given for the first two doses is not available, the other mRNA COVID-19 vaccine product may be administered. A person should not receive more than three mRNA COVID-19 vaccine doses.
Until additional data are available, the additional dose of an mRNA COVID-19 vaccine should be administered at least 28 days after completion of the initial 2-dose mRNA COVID-19 vaccine series, based on expert opinion.
Currently there are insufficient data to support the use of an additional mRNA COVID-19 vaccine dose after a single-dose Janssen COVID-19 vaccination series in immunocompromised people. FDA and CDC are actively working to provide guidance on this issue
BOOSTER DOSE INFORMATION
Currently, CDC is recommending that the following people receive a booster dose at least 6 months after completion of Pfizer primary series. Applies to Pfizer ONLY. Effective 9/24/21for:
people 65 years and older and residents in long-term care settings should receive a booster shot of Pfizer-BioNTech’s COVID19 vaccine at least 6 months after their Pfizer-BioNTech primary series
people aged 50–64 years with underlying medical conditions should receive a booster shot of Pfizer-BioNTech’s COVID-19 vaccine at least 6 months after their Pfizer-BioNTech primary series,
people aged 18–49 years with underlying medical conditions may receive a booster shot of Pfizer-BioNTech’s COVID-19 vaccine at least 6 months after their Pfizer-BioNTech primary series, based on their individual benefits and risks, and
people aged 18-64 years who are at increased risk for COVID-19 exposure and transmission because of occupational or institutional setting may receive a booster shot of Pfizer-BioNTech’s COVID-19 vaccine at least 6 months after their PfizerBioNTech primary series, based on their individual benefits and risks.
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