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

Covid-19 Vaccine Consent Form

* Please fill out the required details below
If you have remaining questions, please call us at (828) 245-4591.
CVMS: _____

1st Dose Scheduled: ______ Closed ______

2nd Dose Scheduled: _____ Closed ______

Insurance: ______
Please click here to find out what group you are in, and if you are eligible to receive the vaccine: Find My Group
What Group are you in per state guidelines? If you do not know, click the above link *

Group 1 Group 2 Group 3 Group 4 Group 5
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: *

Month Day Year
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: *
What dose of COVID-19 vaccine will this be? *

First Dose Second Dose N/A
When did you receive your first dose? *

Month Day Year
Date
Section II. Questionnaire for Immunization

Please select the correct option below: *

Yes

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), 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
Section IV: Insurance information

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

Browse Files

Cancel of
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.
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Covid-19 Vaccine Consent Form

Section IV: Insurance information