COVID Vaccine Consent Form - (Smith’s Drugs of Forest City)

If you have remaining questions, please call us at (828) 245-4591.

Pfizer:_____ Moderna:_____

CVMS: _____

1st Dose Scheduled: ______ Closed ______

2nd Dose Scheduled: _____ Closed ______

3rd Dose:______Closed______

Insurance: ______

What dose of COVID-19 vaccine will this be? *

First Dose Second Dose Third Dose N/A

Currently, only certain patients qualify for the third dose. Please select one of the following that applies to you:

Been receiving active cancer treatment for tumors or cancers of the blood Received an organ transplant and taking medication to suppress immune system Received stem cell transplant in last 2 years or taking medication to suppress your immune system Moderate to severe immunodeficiency (DiGeorge syndrome, Wiskott-Aldrich syndrome Advanced or untreated HIV infection Active treatment with high dose corticosteroids or other drugs that suppress your immune response None of the above

When did you receive your first/second dose? *

Date

Please pick a day and time for your vaccination *

Section I. Personal Information

Patient's Full Name: *

First Name Ml Last Name

Date of Birth: *

Age: *

Cell Phone Number: *

Home Phone Number (if not different than cell, put same number) *

Area Code Phone Number

Email: *

Gender: *

Male Female

Ethnicity: *

Hispanic or Latino Non Hispanic/Latino Unknown Prefer not to answer

Race: *

African American American Indian Asian Caucasian Native Hawaiian/Other Pacific Islander Prefer not to answer

Address: *

Street Address Line 2

Mother's Maiden Name

First Name Last Name

Medical Conditions:

Primary Care Doctor: *

Doctor City/State: *

Section II. Questionnaire for Immunization

Please select the correct option below: *

	Yes	No	Don't know or N/A
COVID-19 Screening Questions: In the past two weeks, have you tested positive for COVID-19 or are you currently being monitored for COVID-19?
In the past two weeks, have you had a known exposure with anyone who tested positive for COVID-19?
Have you had a new onset of fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, nausea, vomiting, or diarrhea?
Questionnaire for Immunization: Do you feel sick today?
Do you have an allergy to medications, foods, or any vaccines (eggs, gelatin, thimerosal, neomycin, gentamicin, latex, aluminum, preservatives, baker's yeast, etc.)?
Do you carry an EpiPen?
Have you received COVID-19 monoclonal antibodies or convalescent plasma in the last 90 days?
Have you ever had a serious reaction or fainted after receiving any vaccination?
Have you ever had a seizure, brain disorder, or Guillain-Barre Syndrome?
Have you ever had dermal fillers?
For women: Are you pregnant or are you planning on becoming pregnant during the next month?

Please specify the allergy from Q2:

To help us select appropriate needle size, please select your weight *

Female less than 200 pounds Female greater than 200 pounds Male less than 260 pounds Male greater than 260 pounds

Section III. Appointment Scheduler

**Vaccine supply is limited. Please keep your appointment or call if you need to cancel or change it. Additionally, due to vaccine requirements; we may call you to see if you can come earlier, later or to a nearby location. If you miss an appointment, no doses will be held to guarantee your dose.**

Section IV. Signatures

I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) (Moderna EUA) (Johnson&Johnson) (Pfizer), a copy of which I was provided with this Consent and Release. I have also been briefed on V-Safe (V-Safe), which I will use to report any side effects I may experience due to the vaccine. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent and Release.

Signature of Person to Receive Vaccine & EUA/VIS (or Signature of Parent/Guardian if Patient is < 18 yo) *

Clear

I have received a copy of the notice of Privacy Practices. I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.

Signature of Acknowledgment of Notice of Privacy Practices: *

Clear

Please take or upload pictures of front & back of insurance card for billing purposes

Browse Files

Insurance authorization

I authorize the pharmacy to bill my insurance on my behalf for the immunization

If uninsured, you must check the box below to attest that the following information is true and accurate:

I do not have any insurance, including but not limited to Medicare, Medicaid or any other private or government-funded health benefit plan

In order to have your vaccine administration fee paid for by the United States Health Resources & Services Administration's COVID-19 Program for uninsured patients, please select to provide one of the following: *

Social Security Number State identification number and state of issuance Driver's license number and state of issuance

Social Security Number *

State identification number and state of issuance *

Driver's license number and state of issuance *

By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.

Covid-19 Vaccine Consent Form

Section IV: Insurance information