Vaccine Consent Form

Information you will need

• What's the patient's first name?
• What's the patient's last name?
• What's the patient's date of birth?
• How old is the patient?
• What’s the patient’s gender?
• What’s the patient’s phone number?
• What’s the patient’s city?
• What’s the patient’s state?
• What’s the patient’s ZIP code?
• What’s the patient’s email address?
• What’s the patient’s race?
• What’s the patient’s ethnicity?
• What’s the patient’s unlisted race?
• What’s the name of the patient’s doctor/primary care provider?
• What’s the doctor/care provider’s phone number?
• What’s the patient’s home address?
• What’s the doctor/care provider's address?
• What’s the doctor/care provider's city?
• What’s the doctor/care provider's state?
• What’s the doctor/care provider's ZIP code?
• What vaccine does the patient want to receive?
• Does the patient feel sick today?
• Has the patient been tested or diagnosed with COVID 19 within the last 14 days?
• Has the patient been in close contact with someone who has COVID 19 within the last 14 days?

…and 67 more fields in the PDF.

Completed by the provider.