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Covid Pediatric Consent -Form Fill

Section One
Q1

Age*
Q2

How many doses of COVID-19 vaccine have you received?
Q3

Email
Q4

Phone*
Q5

Address*

Address
Q6

Address*
Q7

Address*

City
Q8

Address*

State
Q9

Address*

Zip Code
Q10

Gender*
Q11

Race*
Q12

Ethnicity*
Q13

Primary Care Doctor
Q14

Primary Care Doctor's City/State
Q15

Do you feel sick today?*
Q16

In the past two weeks, have you tested positive for COVID-19 or are you currently being monitored for COVID-19?*
Q17

In the past 90 days, did you receive any medications, plasma or other treatment for COVID-19?*
Q18

In the past two weeks, have you had a known exposure with anyone who tested positive for COVID-19?*
Q19

Have you been diagnosed with Multisystem Inflammatory Syndrome (MIS-C or MIS-A) after a COVID-19 infection?*
Q20

Have you had a new onset of fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, nausea, vomiting or diarrhea?*
Q21

Do you have an allergy to any food, medication or vaccine?*
Q22

Have you ever had a serious reaction or fainted after receiving any vaccination?*
Q23

Do you carry an EpiPen?*
Q24

Do you have a bleeding disorder or take a blood thinner?*
Q25

Have you ever had a seizure, brain disorder, or Guillain-Barre Syndrome?*
Q26

Do you have a weakened immune system (i.e., HIV infection, cancer) or take immunosuppressive drugs or therapies?*
Q27

Do you have a history of myocarditis or pericarditis?*
Q28

Do you have a history of heparin-induced thrombocytopenia (HIT)?*
Q29

Have you received dermal fillers?*
Q30

FOR WOMEN: Are you currently pregnant or breastfeeding?*
Q31

Acknowledgements
Q32

Signature*
Q33

Parent/Guardian Name*
Q34

Relationship to patient*
Q35

Insurance Information & Authorization
Q36

Social Security #