Forms

BASIC INFORMATION

SS/HIC/Patient ID#

Patient Name *

Race *

American Indian or Alaskan Native Hawaiian Asian Native Hawaiian White Filipino Chinese Japanese Korean Asian Guamanian Samoan Tongan Other Pacific Islander Vietnamese Refused Unknown Other race Canadian and Latin American Indian Catawba Cayuse Chehalis Chemakuan Chemehuevi Cherokee Cherokee Shawnee Cheyenne Cheyenne-Arapaho Chickahominy Chickasaw Chinook Chippewa Chippewa Cree Chitimacha Choctaw Chumash Clear Lake Coeur D'Alene Coharie Colorado River Colville Comanche Native Hawaiian or other Pacific Islander American Indian Alaska Native Asian Indian Bangladeshi Bhutanese Burmese Cambodian Taiwanese Hmong Indonesian Laotian Malaysian Okinawa Pakistani Sri Lankan Thai Iwo Jiman Maldivian Nepalese Singaporean Madagascar Black African American African Bahamian Barbadian Dominican Dominica Islander Haitian Jamaican Tobagoan Trinidadian West Indian Polynesian Micronesian Melanesian European Middle Eastern or North African Arab Abenaki Algonquian Apache Arapaho Arikara Assiniboine Assiniboine Sioux Bannock Blackfeet Brotherton Burt Lake Band Caddo Cahuilla California tribes Modoc Mohegan Mono Nanticoke Narragansett Navajo Nez Perce Nomalaki Northwest Tribes Omaha Oregon Athabaskan Osage Otoe-Missouria Ottawa Paiute Pamunkey Passamaquoddy Pawnee Penobscot Peoria Pequot Pima Piscataway Pit River Pomo Ponca Potawatomi Powhatan Pueblo Puget Sound Salish Quapaw Quinault Rappahannock Reno-Sparks Round Valley Sac and Fox Salinan Salish Salish and Kootenai Schaghticoke Scott Valley Seminole Serrano Shasta Shawnee Shinnecock Shoalwater Bay Shoshone Shoshone Paiute Siletz Sioux Siuslaw Spokane Stewart Stockbridge Susanville Tohono O'Odham Tolowa Tonkawa Tygh Umatilla Umpqua Ute Wailaki Walla-Walla Wampanoag Warm Springs Wascopum Washoe Wichita Wind River Winnebago Winnemucca Wintun Wiyot Yakama Yakama Cowiltz Yaqui Yavapai Apache Yokuts Yuchi Yuman Yurok Alaska Indian Eskimo Aleut Botswanan Ethopian Liberian Namibian Nigerian Zairean Tahitian Tokelauan Guamanian or Chamorro Chamorro Mariana Islander Marshallese Palauan Carolinian Kosraean Pohnpeian Saipanese Kiribati Chuukese Yapese Fijan Papua New Guinean Solomon Islander New Hebrides Armenian English French German Irish Italian Polish Scottish Assyrian Egyptian Iranian Iraqi Lebanese Palestinian Syrian Afghanistani Israeli Chiricahua Fort Sill Apache Jicarila Apache Lipan Apache Mescalero Apache Oklahoma Apache Payson Apache San Carlos Apache White Mountain Apache Nothern Arapaho Southern Arapaho Wind River Arapaho Fort Peck Assiniboine Sioux Oklahoma Cabo Agua Caliente Cahuilla Augustine Cabazon Los Coyotes Morongo Santa Rosa Cahuilla Torres-Martinez Cahto Chimariko Coast Miwok Digger Kawaiisu Kern River Mattole Red Wood Santa Rosa Takelma Wappo Yana Yuki Canadian Indian Central American Indian French American Indian Mexican American Indian South American Indian Spanish American Indian Hoh Quileute Cherokee Alabama Cherokee of Northeast Alabama Cherokee of Southeast Alabama Eastern Cherokee Echota Cherokee Etowah Cherokee Nothern Cherokee Tuscola United Keetowah Band of Cherokee Western Cherokee Nothern Cheyenne Southern Cheyenne Eastern Chickahominy Western Chickahominy Clatsop Columbia River Chinook Kathlamet Upper Chinook Wakiakum Chinook Wilapa Chinook Wishram Bad River Bay Mills Chippewa Bois Forte Burt Lake Chippewa Fond du Lac Grand Portage Grand Traverse Band of Ottawa/ Chippewa Keweenaw Lac Course Oreilles Lac du Flambeau Lac Vieux Desert Chippewa Lake Superior Leech Lake Little Shell Chippewa Mille Lacs Minnesota Chippewa Ontonagon Red Cliff Chippewa Red Lake Chippewa Saginaw Chippewa St. Croix Chippewa Sault Ste. Marie Chippewa Sokoagon Chippewa Turtle Mountain Cook Inlet Copper Center Copper River Dot Lake Doyon Eagle Eklutna Evansville Fort Yukon Gakona Galena Grayling Gulkana Healy Lake Holy Cross Hughes Huslia Iliamna Kaltag Kluti Kaah Knik Koyukuk Lake Minchumina Lime McGrath Manley Hot Springs Mentasta Lake Minto Nenana Nikolai Ninilchik Nondalton Northway Nulato Pedro Bay Rampart Ruby Salamatof Seldovia Slana Shageluk Stevens Stony River Takotna Tanacross Tanaina Tanana Tanana Chiefs Tazlina Telida Tetlin Tok Tyolin Venetie Wiseman Tlingit-Haida Cow Creek Umpqua Allen Canyon Uintah Ute Ute Mountain Ute Gay Head Wampanoag Mashpee Wampanoag Alpine Carson Dresslerville Ho-chunk Nebraska Winnebago Table-bluff Bario Libre Pascua Yaqui Chukchansi Tachi Tule River Cocopa Havasupai Hualapai Maricopa Mohave Quechan Yavapai Coast Yurok Alaskan Athabascan Southeast Alaskan Greenland Eskimo Inupiat Eskimo Siberian Eskimo Yupik Eskimo Alutiiq Aleut Bristol Bay Aleut Chugach Aleut Eyak Koniag Aleut Sugpiaq Suqpigaq Unangan Aleut Ahtna Alatna Alexander Allakaket Alanvik Anvik Arctic Beaver Birch Creek Cantwell Chalkyitsik Chikaloon Chistochina Chitina Circle Duckwater Elko Ely Goshute Panamint Ruby Valley Skull Valley South Fork Shoshone Te-Moak Western Shoshone Timbi-Sha Shoshone Wahakie Wind River Shoshone Yomba Duck Valley Fallon Fort McDermitt Blackfoot Sioux Brule Sioux Cheyenne River Sioux Crow Creek Sioux Dakota Sioux Flandreau Santee Fort Peck Lake Traverse Sioux Lower Brule Sioux Lower Sioux Mdewakanton Sioux Miniconjou Oglala Sioux Pine Ridge Sioux Pipestone Sioux Prairie Island Sioux Rosebud Sioux Sans Arc Sioux Santee Sioux Sisseton-Wahpeton Sisseton Sioux Spirit Lake Sioux Standing Rock Sioux Teton Sioux Two Kettle Sioux Upper Sioux Wahpekute Sioux Wahpeton Sioux Wazhaza Sioux Yankton Sioux Yanktonai Sioux Ak-Chin Gila Bend San Xavier Sells Keres Laguna Nambe Picuris Piro Pojoaque San Felipe San Ildefonso San Juan Pueblo San Juan De San Juan Sandia Santa Ana Santa Clara Santo Domingo Taos Tesuque Tigua Zia Zuni Duwamish Kikiallus Lower Skagit Muckleshoot Nisqually Nooksack Port Madison Puyallup Samish Sauk-Suiattle Skokomish Skykomish Snohomish Snoqualmie Squaxin Island Steilacoom Stillaguamish Swinomish Tulalip Upper Skagit Iowa Sac and Fox Missouri Sac and Fox Oklahoma Sac and Fox Big Cypress Brighton Florida Seminole Hollywood Seminole Oklahoma Seminole San Manual Absentee Shawnee Eastern Shawnee Battle Mountain Oklahoma Ottawa Bishop Bridgeport Burns Paiute Cedarville Fort Bidwell Fort Independence Kaibab Las Vegas Lone Pine Lovelock Malheur Paiute Moapa Northern Paiute Owens Valley Pyramid Lake San Juan Southern Paiute Southern Paiute Summit Lake Utu Utu Gwaitu Paiute Walker River Yerington Paiute Indian Township Pleasant Point Passamaquoddy Oklahoma Pawnee Oklahoma Peoria Marshantucket Pequot Gila River Pima-Maricopa Salt River Pima-Maricopa Central Pomo Dry Creek Eastern Pomo Kashia Northern Pomo Scotts Valley Stonyford Sulphur Bank Nebraska Ponca Oklahoma Ponca Citizen Band Potawatomi

Relationship to patient

Date of birth *

Social security number # *

Cell phone number *

Email address

Address *

Emergency contact name *

Who is your primary care provider (PCP)? *

Insurance Information

Insurance company

Insurance company Address

Insurance Policy ID

Group#

Secondary Insurance Information

Secondary Insurance Name

Policy ID

Group ID

Policy holder's name

Policy Holder's DOB

Policy Holder's SSN

Relationship to Policy Holder

Sounds good, let's get going

Have you had any contact with anyone diagnosed with COVID-19 Corona virus? yes No

Have you ever received a dose of COVID-19 vaccine?* Yes No Don't know

Which vaccine product did you receive? *

Pfizer Moderna Janssen (Johnson & Johnson) Another product

ALLERGIES

Have you ever had an allergic reaction to a component of the COVID-19 vaccine called polyethylene glycol (PEG)?* Yes No Don't know

Have you ever had an allergic reaction to a component of the COVID-19 vaccine called polysorbate? *

Yes No Don't know

Have you ever had an allergic reaction to a vaccine or injectable therapy that contains multiple components, one of which is a COVID-19 vaccine component, but it is not known which component elicited the immediate reaction?* Yes No Don't know

Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication? *

Yes No Don't know

RELEVANT HISTORY

Have you ever had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?* Yes No Don't know

Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies? *

Yes No Don't know

Are you pregnant or breastfeeding?* Yes No Don't know

Do you have dermal fillers? *

Yes No Don't know

Anything else you would like to share

RELEASE AND ASSIGNMENT:

- I have read or had explained to me the Vaccine Recipient Emergency Use Authorization (EUA) Fact Sheet for COVID?19 vaccine risks and benefits. To read the Vaccine Recipient Emergency Use Authorization Fact Sheet for each vaccine visit the website www.cvdvaccine.com: or you may also visit the Local Health Unit or private provider to receive a printed copy of the EUA Fact Sheet. To read the Vaccine Recipient Emergency Use Authorization for Moderna COVID?19 vaccine visit the website https://www.fda.gov/media/144638/download or (modernatx.com) - I give consent to this COVID?19 provider/staff for the individual named above to be vaccinated with COVID?19 vaccine. - I hereby acknowledge that I have reviewed a copy of the Provider’s Privacy Notice. - I understand that information about this COVID?19 vaccination will be included in (IMMTRAC) Texas Immunization Registry.

To My Insurance Carrier(s):

- I authorize the release of any medical information necessary to process my insurance claim(s). - I authorize and request payment of medical benefits directly to this COVID?19 Provider. - I agree that the authorization will cover all medical services rendered until I revoke the authorization. - I agree that the photocopy of this form may be used instead of the original.

Initials of Patient or Guardian (signature)

Today's date

COVID-19 vaccine Contact and Consent form

BASIC INFORMATION

Insurance Information

Secondary Insurance Information

ALLERGIES

RELEVANT HISTORY

RELEASE AND ASSIGNMENT:

To My Insurance Carrier(s):