New River Health Vaccine Consent Form Pfizer COVID-19

Patient Name:

Date of Birth:

YYYY

Parent/Guardian daytime phone number:

Patient Age:

Grade:

Patient Gender:

Male

Female

School Name:

Homeroom Teacher's Name:

Parent/Guardian Name:

Address

Patient Primary Provider:

Primary Provider Address:

Screening for Vaccine Eligibility:

The following questions will help us to know if your child can receive the COVID-19 vaccine. If you answer NO to all of the following questions, your child can probably get the COVID-19 vaccine. If you answer YES or DON’T KNOW to one or more of the following questions, your child may be able to get the COVID-19 vaccine, but we will contact you to discuss your options.

Please mark YES, NO, or DON’T KNOW for each of the following questions.

1. Has your child ever had an allergic reaction: (This would include a severe allergic reaction, e.g. anaphylaxis that required treatment with epinephrine or EpiPen® or that caused them to go to the hospital. It would also include an allergic reaction that occurred within 4 hours causing hives, swelling, or respiratory distress, including wheezing.)

Yes

Don't Know

2. Has your child ever had an allergic reaction to: Polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures.

Yes

Don't Know

3. Has your child ever had an allergic reaction to: Polysorbate, which is found in some vaccines, film coated tablets, and intravenous steroids.

Yes

Don't Know

4. Has your child ever had an allergic reaction to: A previous dose of COVID-19 vaccine.

Yes

Don't Know

5. Has your child 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

Don't Know

6. Has your child ever had an allergic reaction to another vaccine (other than COVID-19) or an injectable medication? (This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused them to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.)

Yes

Don't Know

7. Has your child ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a component of COVID-19 vaccine, or any vaccine or injectable medication? (This would include food, pet, venom, environmental, or oral medication allergies.)

Yes

Don't Know

8. Has your child received any vaccines in the last 14 days?

Yes

Don't Know

9. Has your child ever had a positive test for COVID-19 or has a doctor ever said they had COVID-19?

Yes

Don't Know

10. Has your child received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?

Yes

Don't Know

11. Does your child have a weakened immune system caused by something such as HIV infection or cancer or take immunosuppressive drugs or therapies?

Yes

Don't Know

12. Does your child have a bleeding disorder or take a blood thinner?

Yes

Don't Know

13. Is your child pregnant or breastfeeding?

Yes

Don't Know

14. Does your child receive frequent lip or face dermal fillers?

Yes

Don't Know

Parental Consent:

CONSENT FOR CHILD’S VACCINATION: I have read or had explained to me the COVID-19 Pre-vaccination Checklist and the EUA vaccine information below and understand the risks and benefits of the COVID vaccine to my child. Please check the box below, then sign and date. Please review the EUA Vaccine Information here for the Pfizer Vaccine.

By checking the box and signing below, I GIVE CONSENT to the New River Health Association and its staff for my child named at the top of this form to be vaccinated with the COVID vaccine. This consent will be valid for both vaccines given approximately 3 weeks apart, depending on availability. (If this consent form is not signed, then your child will not be vaccinated.)

YES I GIVE CONSENT

Parent/Guardian Name

Child's Date of BIrth:

YYYY

Date

2025

Parent/Guardian Signature