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

Pfizer:_____ Moderna:_____ Pfizer (5-11):_____

CVMS: _____

1st Dose Scheduled: ______ Closed ______

2nd Dose Scheduled: _____ Closed ______

3rd Dose scheduled ______Closed______

4th Dose scheduled ______Closed______

billed in PC_____manual bill______no ins____

ask for ins cards YES/NO______________

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

The following questions will help us determine if there is any reason you should not get the COVID-19 vaccine today. If you answer "yes" to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions may be asked. If a question is not clear, please as your healthcare provider to explain it.

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

1st Dose 2nd Dose 3rd Dose 4th Dose

Please select correct age group: *

5-11 years old (Pfizer ONLY) 12-15 years old (Pfizer ONLY) 16-17 years old (Pfizer ONLY) 18 & older (Pfizer or Moderna)

If 2nd dose, which vaccine did you receive for 1st dose?

PFIZER MODERNA

If 3rd or 4th dose, (BOOSTER), which vaccine would you like?

PFIZER MODERNA

PFIZER and MODERNA recipients ONLY. Please select one of the following that applies to you. Note, this is only if you received Pfizer or MODERNA for your first and second dose.

18 and older

When did you receive your last dose? *

Date

Do you have your vaccine card? If yes, please bring to appointment. *

YES NO

Please pick a day and time for your vaccination *

Section I. Personal Information

Patient's Full Name: *

First Name Middle Name 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: Please provide personal email to receive online access to your records *

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
Are you feeling sick today?
Female between ages 18 and 49 years old?
Am a male between ages 12 and 29 years old
Have a history of myocarditis or pericarditis
Have you ever had an allergic reaction to another vaccine (other than a COVID-19 vaccine) or an injectable medication? This would include a severe allergic reaction (anaphylaxis) that required treatment with epinephrine or EpiPen or that caused you to go to the hospital. It would also include an allergic reaction that caused hives, swelling, or respiratory distress (including wheezing.)
Had COVID-19 and was treated with monoclonal antibiodies or convalescent serum to prevent or treat Covid-19
Diagnosed with Multisystem Inflammatory Syndrome(MIS-C or MIS-A) after a COVID-19 infection
Have a bleeding disorder
Take a blood thinner
have a history of heparin-induced thrombocytopenia (HIT)
Am currently pregnant or breastfeeding
Have received dermal fillers
History of Guillain-Barre Syndrome (GBS)
Have you ever had an allergic reaction to polyethylene glycol(PEG) which is found in some laxatives and preparations for colonoscopy procedures
have you ever had an allergic reation to polysorbate, which is found in some vaccines, film coated tablets, and intravenous steroids
have you ever had an allergic reaction to a previous dose of a COVID-19 vaccine
Have you received hematopoietic cell transplant (HCT) or CAR-T cell therapies since recivnig COVID-19 vaccine?

Please specify the allergy from Q5:

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/Spikevax) (Johnson&Johnson) (Pfizer/Comirnaty), 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.

Printed Name of Legally Authorized Representative: First & Last Name

Signature of Person to Receive Vaccine & EUA/VIS (or Signature of Parent/Guardian/Legally Authorized Representative 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. In order for us to be able to read this information, please select the image for the insurance card to be cropped so that there is very little blank space around the insurance card.

Browse Files

Covid-19 Vaccine Consent Form

Section IV: Insurance information