myVax™ - Intelligent, Patient-centered Health Platform

COVID-19 Testing/Vaccine Consent under Emergency Use Authorization

Step 1: Account Set up

Member Information

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Cell Phone

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Step 2: Patient Registration

Mandatory Field:

Last Name

First Name

Middle Initial

Maiden Name

Date of Birth

Gender

Street Address

City

State

Zip Code

Home Phone

Step 3: Medical Insurance Information

Medical Insurance:	Medicare	Medicaid	Private
Other		None	Member ID:

Step 4: Pharmacy Insurance Information

Insurance Name

RxBIN

RxPCN

RxGRP

Policy Number

Step 5: Health History

	HEALTH HISTORY	Yes	No	Unknown
1	Are you feeling sick today?
2	Have you ever had a severe allergic reaction (e.g., anaphylaxis) to a component of COVID-19 vaccine or a previous dose of COVID-19 vaccine, polysorbate, polyethylene glycol (found in some medications, such as laxatives and preparations for colonoscopies)?
3	Have you ever had a serious reaction after any vaccination or injectable medication including a previous dose of the COVID-19 vaccine, food, pet, environmental, or oral medication allergies?
4	In the past 14 days have you had contact with a confirmed COVID-19 patient?
5	In the past 14 days, have you had a positive test for COVID-19 or has a doctor told you that you have COVID-19?
6	Are you breastfeeding or pregnant?
7	Have you received passive antibody therapy or convalescent plasma as a treatment for COVID-19 in the last 90 days?
8	Are you immunocompromised? (taking medication or being treated for cancer, leukemia, HIV/AIDS or other immune system problems or taking medication that affects your immune system)
8a	Do you have a heart disease?
8b	Do you have diabetes? (Type I or Type II)
8c	Do you have a chronic kidney disease?
8d	Do you have a chronic lung disease? (Asthma, COPD, Emphysema)
8e	Do you have a neurologic disease? (Alzheimer’s, Amyotrophic Lateral Sclerosis, Bell’s Palsy, Epilepsy/Seizures, etc.)
9	Do you have a bleeding disorder or are you taking a blood thinner?
10	In the last 28 days (Moderna) or 21 days (Pfizer) have you ever received a dose of COVID-19 vaccine?
11	Have you received any vaccinations in the last 14 days?

Step 6: Consent Form

Consent FORM for COVID-19 Vaccination and Testing

I certify that I am: (a) the patient and at least 16 years of age (5 years of age if Pfizer-BioNTech) (Vaccination); (b) the legal guardian of the patient and confirm that the patient is at least 16 years of age (5 years of age if Pfizer-BioNTech); or (c) legally authorized to consent for vaccination or COVID-19 diagnostic testing for the patient named above. Further, I hereby give my consent to the Georgia Department of Public Health (DPH) its agents to administer the COVID-19 vaccine and/or COVID-19 diagnostic testing.
I understand that this vaccine has received emergency use authorization (EUA) by the FDA to prevent Coronavirus Disease 2019 (COVID-19) for use in individuals either 16 years of age or older or 18 years of age and older but has not been approved or licensed by FDA at this time. I further understand that emergency use of this product is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of the medical product under Section 564(b)(1) of the FD&C Act unless the declaration is terminated or authorization revoked sooner, or the product receives full approval.
I understand that my COVID-19 diagnostic test may require the collection of an appropriate sample by my healthcare provider through nasopharyngeal swab, oral swab, or other recommended collection procedures. I understand that there are risks and benefits associated with undergoing a diagnostic test for COVID-19 and there may be a potential for false positive or false negative test results. Should I have questions or concerns regarding my results I will seek advice from an appropriate medical provider.
I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccine(s). I understand the risks and benefits associated with the above vaccine(s)and have received, read and/or had explained to me the Emergency Use Authorization Fact Sheet on the COVID-19 vaccine I have elected to receive. I also acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction.
I acknowledge that I have been advised to remain near the vaccination location for approximately 15 minutes (or more in specific cases) after administration for observation. If, after I leave the vaccination site, I experience a severe reaction or worsening of my condition, I will call 9-1-1 or go to the nearest hospital.
On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless the State of Georgia, Georgia Department of Public Health (GDPH), the DPH Division of Communications, Emergency Preparedness and Response (EPR), Emergency Operations Plan (EOP) and their staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the vaccine listed above.
I acknowledge that: (a) I understand the purposes/benefits of Georgia Immunization Portal (GIP), Georgia Registry of Immunization Transaction and Services (GRITS) and (b) DPH will include my personal immunization information in GRITS and my personal immunization information, and my test results will be shared with the Centers for Disease Control (CDC) or other federal agencies.
I further authorize GDPH, GRITS or its agents to submit a claim to my insurance provider or Medicare Part B without supplemental coverage payment for me for the above requested items and services. I assign and request payment of authorized benefits be made on my behalf to DPH, GRITS or its agents with respect to the above requested items and services. I understand that any payment for which I am financially responsible is due at the time of service or if DPH invoices me after the time of service, upon receipt of such invoice.
I acknowledge receipt of the DPH Notice of Privacy Practices.

Print Name of Person Receiving Vaccine or Authorized Representative:

Signature of Person Receiving Vaccine or Authorized Representative:

TODAY'S DATE

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