VACCINE CONSENT FORM

STUDENT INFORMATION

IF YOUR SCHOOL'S CLINIC IS WITHIN THE NEXT 4 SCHOOL DAYS, YOUR
REGISTRATION MAY NOT BE REVIEWED IN TIME. YOUR TEEN WILL BE SCHEDULED
FOR THE NEXT CLINIC.

School *

Year of Graduation *

Email Address

Student Last Name *

Student First Name *

Date of Birth *

Street Address *

City *

State *

Zip Code *

Sex (assigned at birth) *

Male

Female

Gender Identity (optional):

Race: *

Ethnicity: *

Hispanic or Latino

Not Hispanic or Latino

Unknown

Prefer not to answer

Parent/Guardian Name

Daytime Phone Number *

Insurance Company *

Member ID *

Group # (if applicable)

SCREENING FOR ROUTINE VACCINE ELIGIBILITY

1. Does the patient have allergies to medicine, food, a vaccine component, or latex? *

Yes

No

If yes, list: If yes, list:

2. Has the patient ever had a serious reaction to a vaccine in the past? *

Yes

No

If yes, list: If yes, list:

3. Does the patient have a long-term health problem with heart, lung, kidney, or metabolic disease (e.g., diabetes), asthma, a blood disorder, no spleen, a cochlear implant, or a spinal fluid leak? *

Yes

No

4. Is the patient on long-term aspirin therapy? *

Yes

No

5. Has the patient, a sibling, or a parent had a seizure? *

Yes

No

6. Has the patient had a brain or other nervous system problem? *

Yes

No

7. Has the patient ever been diagnosed with a heart condition (myocarditis or pericarditis) or have they had Multisystem Inflammatory Syndrome (MIS-C) after an infection with the virus that causes COVID-19? *

Yes

No

8. Does the patient have an immune-system problem such as cancer, leukemia, HIV/AIDS, or any other immune system problem? *

Yes

No

9. In the past 6 months, has the patient taken medications that affect the immune system such as prednisone, other steroids, or anticancer drugs; drugs to treat rheumatoid arthritis, Crohn's disease, or psoriasis; or had radiation treatments? *

Yes

No

10. Does the patient's parent or sibling(s) have an immune system problem? *

Yes

No

11. In the past year, has the patient received immune (gamma) globulin, blood/blood products, or an antiviral drug? *

Yes

No

12. Has the patient received any vaccinations in the past 4 weeks? If yes, please list. *

Yes

No

List Vaccinations below:

13. Has the patient ever felt dizzy or faint before, during, or after a shot? *

Yes

No

CONSENT FOR VACCINATION

I have viewed the Vaccine Information Statement(s) for the vaccine(s) requested at www.immunize.org or received a printed copy to review. I understand the benefits and risks of the vaccine(s) requested. I understand that a record of vaccinations administered in this program will be submitted to the statewide database, RICAIR within 48 hours of vaccination. I hereby release The Wellness Company from any and all liability associated with the administration and potential side effects of the vaccine.

In accordance with RIGL 23-4, 6-1 students age 16 or older may consent to routine, emergency, medical or surgical care. A minor parent may consent to treatment of their child.

REQUIRED VACCINES

I would like to receive the following REQUIRED vaccine(s). Check all that apply.

Hepatitis B (3 doses)

HPV - Gardasil (Human Papillomavirus, 2-3 doses)

MMR (Measles, Mumps & Rubella, 2 doses)

Meningitis A, C, W, Y (1-2 doses required)

Polio (3-4 doses)

Tdap (Tetanus, Diphtheria, Pertussis)/Td

Varicella (2 doses)

RECOMMENDED VACCINES

The vaccine(s) checked should be given to the student named for whom I am authorized to make this request. I understand that all doses indicated for each vaccine are needed to receive full protection. Signature for a vaccine provides consent to receive all doses needed for that vaccine.

I would like to receive the following RECOMMENDED vaccine(s). Check all that apply.

CONSENT FOR VACCINATION--YOU MUST SIGN HERE FOR YOU/MINOR TO BE VACCINATED

By signing this form I give permission for a vaccine to be adminstered to the person above and a record of the vaccination to be entered into the Rhode Island Child and Adult Immunization Registry (RICAIR) for care coordination and to monitor statewide vaccination coverage. For more information about RICAIR, please go to https://health.ri.gov/ricair Further, I agree that the information above is correct.

I have reviewed the Privacy Practice notice *

Yes

Privacy Practice Notice

Vaccine Information Statements

COVID Resources-Moderna

COVID Resources-Pfizer

I have reviewed the Vaccine Information Statements *

Yes

By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.

First Name *

Last Name *

Relation to Client *

Date: * +