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COVID-19 Vaccine Consent Form Template

Streamline your patient consent process with this easy-to-use template

Getting the right consent for COVID-19 vaccinations can feel overwhelming, but it doesn't have to be. This COVID-19 vaccine consent form template helps healthcare providers like you efficiently collect patient consent, ensuring compliance with legal requirements while simplifying the process. You can easily customize the form, share it with patients online, and gather signatures securely, providing peace of mind and professional integrity. Plus, it works seamlessly on any device for quick access and completion. Start using the live template to see how it can improve your workflow.

Use this Template (FREE) Live Preview
Full legal name
Date of birth
Gender identity
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Email address
Mobile phone number
Mailing address
Preferred contact method
Email
Phone
Text message
No preference
Emergency contact full name
Emergency contact phone number
Do you need an interpreter?
Yes
No
Vaccine product to be administered today
Pfizer-BioNTech (mRNA)
Moderna (mRNA)
Novavax (protein-based)
Unsure / To be determined
Dose number today
First dose
Second dose
Additional / Booster dose
Unknown / Not applicable
Have you previously received a COVID-19 vaccine?
Yes
No
Date of most recent COVID-19 vaccine
Previous COVID-19 vaccine product received (if any)
Pfizer-BioNTech (mRNA)
Moderna (mRNA)
Novavax (protein-based)
Not applicable
Unsure
Other
Please Specify:
Are you feeling sick today?
Yes
No
Have you ever had a severe allergic reaction (e.g., anaphylaxis) to a vaccine, injectable medication, or any ingredient?
Yes
No
Unsure
Have you had an allergic reaction after a previous dose of a COVID-19 vaccine?
Yes
No
Unsure
Do you have a known allergy to polyethylene glycol (PEG) or polysorbate?
Yes
No
Unsure
Have you tested positive for COVID-19 or been told to isolate in the last 10 days?
Yes
No
Have you received monoclonal antibody or antiviral treatment for COVID-19 in the last 90 days?
Yes
No
Unsure
Do you have a weakened immune system or take immunosuppressive therapy?
Yes
No
Do you have a bleeding disorder or take blood thinners?
Yes
No
Do you have a history of fainting after injections?
Yes
No
Primary care provider name
Are you pregnant, planning to become pregnant, or breastfeeding?
Pregnant
Planning to become pregnant
Breastfeeding
None of the above
Prefer not to say
I have reviewed the COVID-19 vaccine information (e.g., Fact Sheet) and understand the risks and benefits.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
I had the opportunity to ask questions, and they were answered to my satisfaction.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
I consent to receive the COVID-19 vaccine today.
Yes
No
I authorize release of my immunization information to the applicable immunization registry as allowed by law.
Yes
No
I authorize billing of my insurance or an applicable program for this vaccination, if available.
Yes
No
Name of person giving consent (type your full name)
Consent date
Relationship to patient
Self
Parent / Legal guardian
Power of attorney / Representative
Other
Please Specify:
Administration site
Left deltoid
Right deltoid
Left thigh
Right thigh
Other
Please Specify:
Vaccine lot number
Vaccine expiration date
Administrator name
Post-vaccination observation completed without incident
Yes
No
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Paper art illustration representing a flu shot proof form for FormCreatorAI article.

When to use this form

Use this consent form whenever you plan to administer a COVID-19 vaccine in a clinic, pharmacy, school, or on-site event. It helps you capture legal authorization, screen for safety, and document the dose, lot, and site. Set it up for new patients, boosters, pediatric visits with guardians, or mobile teams serving homebound adults. To confirm eligibility up front, pair it with the COVID-19 Vaccine self-certification form. When a parent or caregiver must sign, add a Medical treatment authorization form to verify authority. The result: faster check-in, fewer errors, clear records for your EHR and state registry, and cleaner audit trails if you are submitting reports or billing.

Must Ask COVID-19 Vaccine Consent Questions

  1. What is your full name, date of birth, and contact information?

    You need verified identity to match records and avoid duplicates in your EHR or registry. Clear contact details enable follow-up for boosters or adverse event checks.

  2. Have you received any COVID-19 vaccine before? If yes, list the manufacturer and dates.

    This ensures you follow correct intervals and product guidance. It also prevents product-mixing errors and supports accurate reporting.

  3. Do you have any allergies or a history of severe reactions to vaccines, medications, or injectables?

    Allergy history guides observation time and may require referral. Capturing specifics (for example, anaphylaxis to PEG) helps you decide whether to proceed today.

  4. Are you currently ill, pregnant or breastfeeding, immunocompromised, or taking blood thinners?

    These conditions affect timing, needle size, counseling, and post-shot care. Screening now reduces adverse events and supports informed consent.

  5. Do you consent to receive the vaccine today and authorize sharing your record with the state immunization registry?

    Documenting consent meets legal requirements and enables reminders and reporting. If someone declines, record the reason for compliance using a model like the Flu vaccine declination form.

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