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* Required Information

Patient Information

Please provide your full legal name as it appears on your driver's license, state identification card, or health insurance card.
 
*Name:
 
 
 
*Date of Birth:
 
 
 
Age:
 
*Gender:
 
Address:
 
City:
 
State:
 
Zip:
 
Phone Number:
 

Cell Phone:
 
*Email:
 
*Race:
 
*Ethnicity:
 

Employer:
 
*LSUHSC Employee ID:
 
Check any that apply and notify the nurse prior to administration.
*Are you experiencing any COVID-like symptoms including but not limited to fever (>100.0), shortness of breath, dry cough, runny nose, sore throat, muscle pain, or loss of taste or smell?
*Have you been diagnosed with any of the following conditions?
  • HIV Infection
  • Immunosuppression (weakened immune system)
  • Autoimmune conditions
*Have you received monoclonal antibodies or convalescent plasma for treatment of COVID-19 infection in the past 90 days?
*Have you received a dose of the COVID-19 vaccine before?
*Have you received any vaccinations in the past 14 days?
*Are you pregnant or breastfeeding or is there a chance you could become pregnant during the next month?
*Do you have a significant history of allergic reactions to vaccines, medicine, or food, such as an anaphylactoid reaction, or have you been advised to carry an adrenaline autoinjector with you (EpiPen)?
If you answered yes to any of the questions above, you may want to speak with your physician before receiving the vaccine.
I have received Emergency Use Authorization of the COVID-19 Vaccine Fact Sheet for Recipients and Caregivers about the COVID-19 vaccine and have had chance to ask questions and had them answered to my satisfaction.
  • I understand that the common side effects for adults include soreness and redness at the injection site, fever, muscle aches, headaches, and tiredness.
  • I have read the information provided on this form, and I have answered all questions honestly.
  • I give my permission to release this COVID-19 documentation to other medical care providers to avoid unnecessary vaccinations and to determine immunization status.
  • I understand that I am to wait 15 - 30 minutes after receiving the COVID-19 vaccine before leaving the building.
  • As recommended, I have discussed any situation (and others) listed above with my healthcare provider and agree to proceed with the COVID-19 vaccination.
  • I understand the benefits and risks of the COVID-19 vaccine and I hereby authorize and consent to receive the vaccination.
I GIVE CONSENT to Louisiana State University Health Sciences Center New Orleans (LINKS Organization ID #1680) to vaccinate me for the COVID-19 virus.
I also agree to allow information about all vaccinations given to me or to the person from whom I am authorized to consent to be release to other medical care providers or schools to avoid the administration of unnecessary vaccinations and to determine immunization status. I understand this will remain in effect until canceled by me in writing.
*Are you the Parent or Guardian?
*Relationship to Recipient:
Date:
 
 
Signature of Adult Vaccine Recipient or Parent/Guardian:
 
FOR OFFICE USE ONLY
VACCINE:
_______________________________
VACCINE MANUFACTURER:
_______________________________
 LOT NUMBER: 
__________________________
SITE OF INJECTION: 
left      right
 EXP DATE: 
__________________________
SIGNATURE (include credentials):
______________________________________________________
DATE:
_______________________________
 
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