• Covid-19 Vaccine Consent Form

    * Please fill out the required details below
  • 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.  

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  • Section I. Personal Information

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  • Section II. Questionnaire for Immunization

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  • 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:

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  • 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.

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  • Section IV: Insurance information

    COVID-19 Vaccine is free of charge to patients, however insurance companies do reimburse pharmacies for administration. If you have insurance please upload below AND bring card or a copy with you to your appointment. IF YOU HAVE A MEDICARE PLAN for your meds, until Jan 2022, the old MEDICARE A&B card (red, white and blue paper card) is what we need to bill your vaccine. If you do not have your medicare B card, we will need your social security number in order to look it up. If you do not have insurance the federal government will pay for your administration.
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  • 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.

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