COVID Vaccine Consent Form -PROFESSIONAL PHARMACY

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MODERNA: COVID Vaccine Consent Form - (Federal Partner)

* Prior to filling this form out you will need photos of your social security card and Medicare Part B (Red, White and Blue Card). If you are commercially insured you will need to provide your Pharmacy Benefits Insurance Card. (It will have "RX BIN & PCN" listed on the card.) *
We are only able to vaccinate based on pulished guidance from the CDC. This may not be the same information you have heard on the media or via the FDA. We update our information as quickly as possibly to coordinate with CDC guidelines.

If you have remaining questions, please text (316) 348-8517.
Select an Appointment Day/Time *
Section I. Personal Information
Patient's Legal Name (as it appears on your Medical Insurance Card): *

First Name Ml Last Name
Date of Birth: *

Month Day Year
mm/dd/yyyy
Address: *

Street Address Line 2
Age: *
65
Cell Phone Number: *
Email: *
Biological 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 Other
Which arm would you like your vaccine administered in? (Using your dominant ar will help reduce soreness due to more movement.) *

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

First Dose Second Dose
Have you received ANY Covid-19 Vaccine yet? *(Please note, that we may verify your vaccine history with the state registry).

Yes, J&J Janssen Yes, Moderna Yes, Pfizer Yes, unknown brand No
When did you receive your first dose? *

Month Day Year
Date
Primary Care Doctor: *
Doctor City/State: *
Are you one of the following? (Please attach a photo of your license below with insurance cards)

Aged 65 or older Healthcare Worker K-12 Employee First Responder Grocery or Food Service Retail Worker Factory Worker LTC/Assisted Living Food/Ag Producer Person with chronic condition No, I am not any of the above
Patient's Social Security Number *
111-11-1111
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?
For women: Are you pregnant or are you planning on becoming pregnant during the next month?

Please specify the allergy from Q2:
Section III. Appointment Scheduler
**Vaccine supply is limited. Please keep your appointment . 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 a copy of which I was provided with this Consent and Release. 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. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Professional Pharmacy, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s). I agree to wait for 15 minutes after my vaccine for observation.
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 (Medicare Part B Card, Commerical Insurance or Medicaid Card) *

Please do not skip this step. Your reservation will require this information.
Cancel of
If insured by Medicare, what is your MBI number on your red, white, and blue card? If not insured by Medicare re-enter your SS# *
example: 1EG4-TE5-MK73
Type a question *

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 *
111-11-1111
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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MODERNA: COVID Vaccine Consent Form - (Federal Partner)