COVID-19 Vaccine Medicare Consent Form 🕒 This form takes approximately 5 minutes... Medicare Consent Form Consent Checklist Continued Have you had an allergic reaction to a previous dose of a COVID-19 vaccine? No Yes Have you had anaphylaxis to another vaccine or medication? No Yes Have you had a serious adverse event, that following expert review was attributed to a previous dose of a COVID-19 vaccine? No Yes Have you ever had mastocytosis which has caused recurrent anaphylaxis? No Yes Have you had COVID-19 before? No Yes Do you have a bleeding disorder? No Yes If you are human, leave this field blank. Next