Texas Immunization Registry (ImmTrac2) "*" indicates required fields Patient Vaccine Consent FormFirst Name* Last Name* Email Phone*Voucher ID* Gender*MFDate of Birth* MM slash DD slash YYYY Vaccine Name Dose (ml) Manufacturer NDC# Route VIS/EUA Pub Date Site Dose # Lot # Expiration Date Street Address* Address Line 2 City* State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState* Country*USAMexicoCanadaOtherZIP Code* Races (Choices)* American Indian or Alaska Native Asian Black or African-American Native Hawaiian or Other Pacific Islander White Recipient Refused Other Ethnicity (Choices)* Hispanic or Latino Not Hispanic or Latino Other Vaccination Permission, Release, & Screening Consent Form for AdultsAre you sick today?* Yes No Don’t Know Have you ever had a serious reaction after receiving a vaccine?* Yes No Don’t Know Do you have a long-term health problem with heart, lung, kidney, or metabolic disease (e.g., diabetes), asthma, a blood* Yes No Don’t Know Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?* Yes No Don’t Know Do you have a parent, brother, or sister with an immune system problem?* Yes No Don’t Know In the past 3 months, have you taken medicines that affect your immune system, such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn’s disease, or psoriasis; or have you had radiation treatments?* Yes No Don’t Know During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?* Yes No Don’t Know Are you pregnant or is there a chance you could become pregnant during the next month?* Yes No Don’t Know Have you had a seizure or a brain or other nervous system problem?* Yes No Don’t Know Do you have allergies to medications, food, a vaccine ingredient, or latex?* Yes No Don’t Know Have you received any vaccinations (e.g., flu, shingles, COVID-19) in the past 4 weeks?* Yes No Don’t Know What are you allergic to?* – I authorize the Pharmacy to submit a claim to my insurance for the above requested service(s) and request payments of authorized benefits to be made on my behalf to the pharmacy. – I fully understand that I will ultimately be responsible for any charges if I am not a covered person under the insurance plan I provided, the services are not covered services, or for any co-pays, deductibles, or coinsurance obligations that apply. – I certify that I am the patient and at least 18 years of age, the legal guardian of the patient, or a person authorized to consent on behalf of the patient where the patient is not otherwise competent or unable to consent for themselves. – I have been provided the Vaccine Information Statement or Emergency Use Authorization Fact Sheet for Recipients & Caregivers for the vaccine(s) to be administered and understand the risks and benefits. – I GIVE CONSENT to the pharmacy and its staff for myself, or the person listed above to be vaccinated with the COVID-19 Comirnaty 23-24 vaccine. I hereby certify that the above information is true and correct to the best of my knowledge, and I agree to the terms and conditions stated above. Printed name* Date* MM slash DD slash YYYY The following is to be completed by the health care provider ONLY.Name of Administrator (Print):
