Healthcare Booster Attestation

HEALTHCARE BOOSTER ATTESTATION

Patient Information

Insurance Information

Vaccine Administration

Vaccine administered:    Lot number:

Date of booster dose:    Administration site:

Administering clinic/provider:

Screening Questions (check all that apply)

I have had a confirmed COVID-19 infection within the past 90 days.

I currently have a fever or acute illness.

I am immunocompromised or on immunosuppressive therapy.

I have a known severe allergic reaction (anaphylaxis) to any component of this vaccine.

I experienced a serious adverse reaction to a prior dose of this vaccine; see description below.

Medical History

Attestation and Consent

By signing below, I attest that the information I have provided on this form is true and complete to the best of my knowledge. I request and consent to the administration of the vaccine booster dose identified above. I understand that no medical procedure is without risks and that adverse reactions may occur. I have had the opportunity to ask questions about the vaccine and the provider has answered them to my satisfaction.

I authorize the administering provider to record this vaccination in my medical record and to report vaccination to public health authorities as required. I understand I may withdraw consent at any time prior to administration. I acknowledge that knowingly making a false statement on this attestation may have legal consequences and may affect my eligibility for future services.

I further certify that I meet current eligibility criteria provided to me by the administering provider and that I have disclosed relevant health history and allergies. If I am signing as a legal guardian or authorized representative, I certify that I am authorized to make health care decisions for the patient named above.

Privacy and Authorization

I acknowledge receipt of the facility's privacy practices and consent to the use and disclosure of my protected health information for treatment, payment, and health care operations, including mandatory reporting of vaccinations. I authorize the release of vaccine information to my insurer for billing purposes where applicable.

Acknowledgment

By signing, I acknowledge that I have read and understand the statements above, that I have had an opportunity to ask questions, and that I voluntarily consent to receive the booster vaccination. I understand possible side effects and that follow-up care is available if needed.

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