Vaccine Administration Record (VAR) Informed Consent for Immunizations
SECTION A: Patient demographic information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Gender
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I am the parent/legal guardian filling this form out for a patient under 15 years of age.
Yes
No
SECTION B: The following questions will help us determine which vaccines you may be given today. If you answer “Yes” to any question, it does not necessarily mean you should not be vaccinated. It just means we may need to ask you more questions. If a question is not clear, please ask us to explain it.
1. Are you sick today?
*
Yes
No
Don't Know
2. Do you have allergies to medications, food, a vaccine component, or latex? (i.e., egg protein, formaldehyde, gelatin, neomycin, polymyxin-B, streptomycin, yeast, or 2-phenoxyethanol)
*
Yes
No
Don't Know
3. Have you ever had a serious reaction after receiving a vaccine?
*
Yes
No
Don't Know
4. Do you have a long-term health problem with heart, lung, kidney, or metabolic disease (e.g. diabetes), asthma, a blood disorder, no spleen, complement component deficiency, a cochlear implant, or a spinal fluid leak? Are you on long-term aspirin therapy?
*
Yes
No
Don't Know
5. Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?
*
Yes
No
Don't Know
6. Do you have a parent, brother, or sister with an immune system problem?
*
Yes
No
Don't Know
7. In the past 6 months, have you taken medications that affect your immune system, such as prednisone, other steroids, or anticancer drugs; drugs for treatment of rheumatoid arthritis, Crohn’s disease, or psoriasis; or have you had radiation treatment?
*
Yes
No
Don't Know
8. Have you had a seizure or a brain or other nervous system problem?
*
Yes
No
Don't Know
9. Have you ever been diagnosed with a heart condition (myocarditis or pericarditis) or have you had Multisystem Inflammatory Syndrome (MIS-A or MIS-C) after an infection with the virus that causes COVID-19?
*
Yes
No
Don't Know
10. In the past year, have you received immune (gamma) globulin, blood/blood products, or an antiviral drug?
*
Yes
No
Don't Know
11. FOR WOMEN: Are you pregnant?
Yes
No
Don't Know
12. Have you received any vaccinations in the past 4 weeks?
*
Yes
No
Don't Know
13. Have you ever felt dizzy or faint before, during, or after a shot?
*
Yes
No
Don't Know
14. Are you anxious about getting a shot today?
*
Yes
No
Don't Know
Name of Patient or Parent/Legal Guardian
*
First Name
Last Name
Signature of Patient or Parent/Legal Guardian
*
Date
*
-
Month
-
Day
Year
Date
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