COVID Vaccination - Swaid Vestavia Medical Center

Personal Information About Individual To Receive Vaccine

First Name *

Last Name *

Gender *

Date of Birth

Age *

Social Security #

Primary Phone Number *

Alternate Phone Number

Email Address *

Street Address *

Apartment, suite, etc

City

State

ZIP / Postal Code

Insurance Information

Name of Insurance Company

Member ID Number/Contract Number

Group Number

Relationship to Subscriber:

Subscriber Name (if different than patient)

Subscriber Birthdate

Street Address

Apartment, suite, etc

City

State

ZIP / Postal Code

Secondary Insurance

Member ID/Contract Number

Group Number

Subscriber Name

In the event of an emergency, please provide:

Emergency Contact *

Phone *

Relationship

Vaccination and health-related information

If you answer Yes to questions 1-4, consult a health care provider before receiving the vaccine.

Does the patient have long-term health problems with: immunocompromised condition or taking a medicine that affects your immune system? *YesNo

Have you ever had a life-threatening reaction to any vaccine or to a vaccine component (example eggs, polyethylene glycol, polysorbate, sulfites, thimerosal, gelatin, neomycin or phenol) *YesNo

Which of the vaccine components have you had a reaction to in the past?

For Women: Are you pregnant or considering becoming pregnant in the next three months or currently nursing? *YesNoN/AIf male, check N/A

Has the patient had a seizure or any other brain or other nervous system problem (i.e., Guillain-Barre Syndrome) after receiving vaccine? *YesNo

Has the patient ever received COVID-19 vaccination? *YesNo

Date the patient received the vaccine

Which vaccine did you receive?

I hereby certify that the above history is true and complete to the best of my knowledge. I have received the Emergency Use Authorization (EUA) Fact Sheet. I have had a chance to ask questions that were answered to my satisfaction. I believe I understand the benefits and risks of requested Vaccine and ask that the Vaccine be given to me. If I receive the Moderna vaccine I understand that I will be receiving two (2) doses of vaccine 21 - 28 days apart. I understand that I may not have the full vaccine protection until after the second dose. I understand my information and Vaccine(s) I receive will be entered into the Alabama Department of Public Health Immunization Registry. I give permission for SURGICAL INSTITUTE OF ALABAMA to provide my medical treatment. I allow SURGICAL INSTITUTE OF ALABAMA. to file for insurance benefits to pay for the care I receive. I assign my insurance benefits to be paid directly to SURGICAL INSTITUTE OF ALABAMA. I understand that SURGICAL INSTITUTE OF ALABAMA may have to send my medical record information to my insurance company. I understand I have the right to refuse any procedure or treatment and I have the right to discuss all medical treatments with my clinician. l waive and release all claims I, or anyone claiming by or through me, now have or may hereafter acquire against SURGICAL INSTITUTE OF ALABAMA, and their respective directors, officers, employees, and agents for any damage or injuries if I, or the person named above for whom I am authorized to make this request, contract the illness prevented by the Vaccine, other diseases, or suffer any other adverse reactions following administration of this Vaccine.

You can download the EUA Fact Sheets for each vaccine below:

View the Moderna EUA Fact Sheet

View the Janssen (Johnson & Johnson) EUA Fact Sheet

Signature

Today's Date

Personal Information About Individual To Receive Vaccine

Insurance Information

In the event of an emergency, please provide:

Vaccination and health-related information

If you answer Yes to questions 1-4, consult a health care provider before receiving the vaccine.

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