Publix vaccine consent form: Fill out & sign online

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Click ‘Get Form’ to open the Publix COVID vaccine form in the editor.
Begin by filling in your personal information, including your name, birth date, age, sex, address, and phone number. Ensure all details are accurate for proper identification.
Next, answer the questions regarding precautions and contraindications by marking 'YES' or 'NO' for each item. If you have any allergies or medical conditions listed, be sure to provide additional details where required.
In the acknowledgments section, indicate your consent for vaccination by specifying the vaccine type you wish to receive. Review the statements carefully before signing.
Complete the authorization for assignment of benefits and release of medical information if applicable. This allows Publix to process any insurance claims on your behalf.
Finally, sign and date the form at the bottom. Ensure that you print your name clearly as well.

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