Please complete this form and give your consent before your COVID-19 vaccination.
Healthcare template · 14 fields (11 required) · ~3 min for respondents to complete · Free plan · No credit card · Fully customizable
Set up your covid vaccine intake consent form
Please complete this form and give your consent before your COVID-19 vaccination.
Have a clinician review screening answers before each dose, and store responses in a HIPAA-appropriate setup. Link your vaccine information sheet so patients can read it before signing.
The form separates phone number, date of birth, which dose is this?, which covid-19 vaccine did you receive last? into labeled questions. Review the choices and required fields for your organization before sharing it.
Best practices
Have a clinician review screening answers before each dose, and store responses in a HIPAA-appropriate setup. Link your vaccine information sheet so patients can read it before signing.
Customize the phone number and date of birth questions to match your records and terminology.
Name the team that reviews responses and explain what happens after submission. A requested date, service or approval is not automatically confirmed.
Ask only for information needed for this step. Arrange any sensitive supporting documents through an appropriate private process.
Every field, explained
Patient full name (Name, required)
Email address (Email, required)
Phone number (Phone, required)
Date of birth (Date, required)
Which dose is this? (Single choice, required)
Which COVID-19 vaccine did you receive last? (Dropdown)
Insurance provider (optional) (Short text)
Are you feeling sick today? (Single choice, required)
Have you ever had a serious allergic reaction to a vaccine or injection? (Single choice, required)
Have you had any vaccine in the past 14 days? (Single choice, required)
Are you pregnant or breastfeeding? (Single choice, required)
Allergies or health conditions we should know about (optional) (Long text)
Consent to vaccination (Multiple choice, required)
Patient or guardian signature (Signature, required) — If signing for a minor, the parent or guardian signs here.
Frequently asked questions
What does this covid vaccine intake consent form template collect?
Alongside contact details, it asks for phone number, date of birth, which dose is this?, which covid-19 vaccine did you receive last?, insurance provider (optional), are you feeling sick today?, have you ever had a serious allergic reaction to a vaccine or injection?, have you had any vaccine in the past 14 days?, are you pregnant or breastfeeding?, allergies or health conditions we should know about (optional), consent to vaccination, patient or guardian signature. You can rename questions, change choices and remove fields that your workflow does not need.
How should I use this covid vaccine intake consent form form?
Have a clinician review screening answers before each dose, and store responses in a HIPAA-appropriate setup. Link your vaccine information sheet so patients can read it before signing.
Can I customize the acknowledgment and signature fields?
Yes. Provide your complete reviewed instructions or terms before collecting signatures. The signature field records input; it does not verify identity or guarantee legal effect. You can edit the form and print a copy.