CLINIC #

COVID-19 Vaccine Consent Form

8100 Innovation Park Dr., Ste. 100, Fairfax, VA 22042

Please print CLEARLY

Name of Recipient (First Name, Last Name)

Email____________________________________________ Sex: Male Female Date of Birth / /

MM DD YYYY
Address: ___________________________________________________________________________ Phone Number: ______________________________________

City:_________________________________ State:__________________ Zip Code:_________________

FOR INOVA EMPLOYEES, PERSONNEL and AFFILIATES ONLY

Inova Team Member External Physician/Medical Contractor/NP/PA Volunteer Contractor

Inova Team Member ID # Department _____________________________ Facility/Hospital __________________________

0
I declare that I or my child is 16 years of age or older. I further declare that I or my child:
1. Have not experienced anaphylaxis (difficulty breathing) or severe allergic reactions from a previous vaccination or an injectable medication.
2. Have not had any other vaccinations in the previous 14 days (e.g. MMR, Shingrix, Varicella, or a TB skin test).
3. Is not currently sick with a fever, active respiratory infection or other moderate/severe illness.
4. Has have not received monoclonal antibodies or convalescent plasma for treatment of COVID-19 within the past ninety (90) days.
5. Is not allergic to the following ingredients in the COVID-19 vaccine: mRNA, lipids((4-hydroxybutyl)azanediyl)bis(hexane-6, 1-diyl)bis(2-hexyldecanoate),
2[(polyethylene glycol)-2000]-N, N-ditetradecylacetamide, 1, 2-Distearoyl-sn-glycero-3-phosphocholine, and cholesterol), potassium chloride, monobasic potassium
phosphate, sodium chloride, dibasic sodium phosphate dihydrate and sucrose.
I understand that if I or my child have any of the above conditions, I or my child could be at increased risk of having a negative reaction or problem from the vaccine.
I further declare that if I or my child have any of the following conditions, I have had the opportunity to speak with my or my child’s primary care provider and am making
an informed decision to receive the vaccine or to have my child receive the vaccine:
1. Pregnant, attempting to become pregnant or breastfeeding;
2. Have a bleeding disorder or are on a blood thinner;
3. Are immunocompromised or are taking a medication that affects the immune system (such as cortisone, prednisone, other steroids, or anticancer drugs; drugs for
the treatment of rheumatoid arthritis, Crohn’s disease or psoriasis; HIV/AIDS, cancer, leukemia, ankylosing spondylitis or radiation treatments).

I agree to WAIT near the clinic location for 15 minutes after receiving the vaccine. If I or my child have previously had a severe allergic reaction to a vaccine or injectable
medication, I agree to WAIT near the clinic location for 30 minutes after receiving the vaccine.

I understand that the COVID-19 vaccine is a two-part vaccine series. By signing this consent, I am agreeing that I or my child will receive the first and second part of the
vaccine series.

I understand that the common risks associated with the COVID-19 vaccine include but are not limited to pain, redness or swelling at the site of injection, tiredness, headache,
muscle pain, chills, joint pain, fever, nausea, feeling unwell or swollen lymph nodes (lymphadenopathy). I understand that the vaccine may cause a severe allergic reaction
which can include anaphylaxis (difficulty breathing, swelling of the face and throat, a fast heartbeat, a rash all over the body, dizziness and/or weakness ). I understand that
these may not be all the side effects of the COVID-19 vaccine as the vaccine is still being studied in clinical trials. I also understand that it is not possible to predict all possible
side effects or complications which could be associated with the vaccine. I understand that the long-term side effects or complications of this vaccine are not known at this
time.

I understand that the vaccination is being given by Inova Health System Foundation and its affiliates (collectively Inova). The owner and/or operator of this site, their affiliates,
officers, directors, employees and agents expressly disclaim any responsibility for the vaccination. My consent is given in light of this knowledge, and in consideration of Inova
giving the COVID-19 vaccine. I, for myself and my heirs, administrators, trustees, executors, assigns and successors in interest do hereby agree to release and hold harmless
Inova, its subsidiaries, divisions, affiliates, successors, assigns, officers, trustees, employees, vo lunteers and agents from and against any and all demands, damages, losses,
costs, expenses, obligations, liabilities, claims, actions and cause of action (whether any of which is groundless or otherwi se) of any nature whatsoever (including, without
limitation, reasonable attorney’s fees and court costs) by reason of or resulting, in any way, from any and all acts, accidents, eve nts, occurrences, omissions and the like
related to, or arising out of, directly or indirectly, my receipt of this COVID-19 vaccine. Inova makes no warranties, express or implied, including but not limited to, implied
warranties of merchantability or fitness for a particular purpose regarding the vaccine or its effectiveness. I acknowledge receipt of Inova’s Notice of Privacy Practi ces.

Medicare Part B Recipients: I understand Inova will process Medicare Part B claims on my behalf and accepts Medicare payment in full. I understand I must present my
Medicare card prior to receiving the vaccine. I understand that if I have assigned my Medicare benefits to a Medicare Advantage Plan (like an HMO or PPO), I must receive my
COVID-19 vaccine shot from my HMO/managed care provider or pay the Inova charge.

Private Insurance Participants: If I have private insurance, I understand that Ino va will not bill my insurance carrier on my behalf, and that I am responsible for paying the
required fee for this vaccine to Inova and for pursuing reimbursement from my health insurance carrier. Inova cannot guarant ee that this service will be reimbursable by
insurance.

I have read and understood “What To Do If You Have A Reaction To The COVID-19 Vaccination” and the “Fact Sheet” by the FDA regarding the COVID-19 Vaccination. I further
understand and agree that Inova is required to submit COVID-19 vaccine administration data to the Virginia Immunization Information System (VIIS), and report moderate and
severe adverse events following vaccination to the Vaccine Adverse Event Reporting System (VAERS).

I understand and agree to all of the above and I hereby give my consent to the staff of Inova to give me or my child a COVID-19 vaccine.

Signature of Patient/Parent:___________________________________________________________________________ Date:___________________________________

Vaccine Lot # & Exp. Date Route Administered by (legal signature and title) Amount Paid Method
Lot # _________________ IM RD LD Cash/Check Certificate
Exp. Date______________ $_____________ Credit Medicare
IHS (12/20) Distribution: White Copy (original) – Inova Yellow Copy – Vaccine Recipient Dx Code: ______ IHS Tax ID # 54-0620889
CLINIC #
COVID-19 Vaccine Consent Form
8100 Innovation Park Dr., Ste. 100, Fairfax, VA 22042

Billable Inova

IHS (12/20) Distribution: White Copy (original) – Inova Yellow Copy – Vaccine Recipient Dx Code: ______ IHS Tax ID # 54-0620889
CLINIC #
COVID-19 Vaccine Consent Form
8100 Innovation Park Dr., Ste. 100, Fairfax, VA 22042

WHAT TO DO IF YOU HAVE A REACTION TO THE COVID-19 VACCINATION

 Most people have side effects from the vaccination, but these usually only last 24 – 48 hours after receipt of the vaccination. A few people may
have no side effects at all. Most people will experience pain, redness and/or soreness at the injection site. Many people will have a headache,
fever, chills, muscle pain and/or fatigue from the vaccine, particularly after the second dose. A few people will have nausea or swollen lymph
nodes (lymphadenopathy).
 In rare circumstances, the vaccine may cause a severe allergic reaction which can include anaphylaxis (difficulty breathing, swelling of the fac e
and throat, a fast heartbeat, a rash all over the body, dizziness and/or weakness).

What should you do if you have a reaction?

If you experience any of the following:

 Red, sore arm at and around the injection site:

o Apply an ice pack to the affected area for comfort.
o If condition does not improve or worsens in 24 to 48 hours, call your physician.
 Fever, achiness, fatigue and/or headache:
o Take the non-prescription product that you would usually use for discomfort or fever relief as needed.
o If condition does not improve or worsens in 24 – 48 hours, call your physician.
 Unusual or severe reaction (for example, hives, difficulty breathing, wheezing, allergic reaction):
o Immediately call your physician, call 911 or go to the emergency room or nearest urgent care center.
 If you have seen your physician or visited the emergency room or an urgent care in relation to any of the reactions listed ab ove, please notify
Inova staff by calling our hotline at 571-472-0321 to leave a message at the end of the voicemail message. A nurse will return your call within 24
hours.
 In addition, you may report vaccine side effects to the FDA/CDC Vaccine Adverse Event Reporting System (VAERS). The VAERS to ll-free number is
1-800-822-7967 or report online to https://vaers.hhs.gov/reportevent.html Please include “Pfizer-BioNTech COVID-19 Vaccine EUA” in the first
line of box #18 of the report form.

Information about the COVID-19 Vaccine

 The COVID-19 vaccines are not live virus vaccines so the vaccines cannot infect anyone with COVID-19.
 All needles and syringes are sterile, are one-time use and are safely discarded.
 According to data, the COVID-19 vaccine has approximately a 94% success rate in completely protecting those who receive it. The remainder
have partial protection and will have greatly lessened symptoms if they do contract COVID-19.
 The vaccine will begin to provide protection about one to two weeks after the second shot of the series is given.
 At this time, we do not know how long the COVID-19 vaccine is effective for, so you may need future vaccines to remain protected.
 While the COVID-19 vaccination does provide protection against infection or greatly lessened symptoms if you contract COVID-19, you should
continue to practice hand hygiene and use appropriate personal protective equipment (PPE).

IHS (12/20) Distribution: White Copy (original) – Inova Yellow Copy – Vaccine Recipient Dx Code: ______ IHS Tax ID # 54-0620889