COVID Vaccine Consent Form

Medicare Part B Insurance Card Information

Please input each of the following for your insurance card
Full Name (as it appears on your Medicare Part B card)*
Medicare Number *
Medicare Part B Start Date (xx/xx/xxxx)*
Authorization*

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

CO Medicaid

Please enter your CO Medicaid ID Number
Medicaid ID*
Authorization*

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

Insurance Card Information

Please upload a picture or input each of the following for your insurance card
Please take or upload pictures of front & back of insurance card for billing purposes

Browse Files

Cancelof
OR
Bin number*
PCN
Rx Group
Identification Number*
Authorization*

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

Uninsured

Even if you are uninsured you are still able to receive the COVID vaccine an no cost to you.
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 planI do have insurance (please select BACK button and chose a different option)
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 NumberDriver's license number and state of issuance
Social Security Number
Driver's license number and state of issuance
DL# / State

Section V. Appointment Scheduling

Please read the following notices. Once you submit you will be redirected to the scheduling page to book your appointment.
*VACCINE SUPPLY IS LIMITED. PLEASE KEEP YOUR APPOINTMENT OR CALL IF YOU NEED TO CANCEL OR CHANGE IT. ADDITIONALLY, DUE TO VACCINE REQURIEMTNS; WE MAY CALL YOU TO SEE IF YOU CAN COME IN EARLIER, LATER, GO TO A DIFFERENT LOCATION OR RESCHEDULE TO A DIFFERENT DAY. IF YOU MISS AN APPOINTMENT, NO DOSES WILL BE HELD TO GUARANTEE YOUR DOSE.*

****IF YOU SCHEDULED TO RECIEVE THE VACCINE AT ANOTHER LOCATION. PLEASE CONTACT THAT ORGANIZATION TO CANCEL YOUR APPOINTMENT ONCE YOU RECEIVE YOUR FIRST DOSE AT OUR PHARMACY****
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.

For Immunizing Staff Use Only

Vaccine product: Moderna COVID19 Vac. (bivalent/monovalent)

Exp Lot

Administered by(print)

Signature:

EUA Published Date monvalent (8/31/22);bivalent (8/31/22)

Dose number 1st / 2nd / booster

NDC see attached back tag

Route IM Volume 0.5ml Site L.Arm / R.Arm

Credentials PharmD / Intern Pharm. / PhTech

Administration Date

EUA given to patient (date)

Should be Empty:

	Yes	No	Don't know or N/A
COVID-19 Screening Questions: 1. In the past two weeks, have you tested positive for COVID-19 or are you currently being monitored for COVID-19?
2. Is the person to be vaccinated have a health condition or undergoing treatment that makes them moderately or severely immunocompromised? This would include, but not limited to, treatment for cancer, HIV, receipt of organ transplant, immunosuppressive therapy or high-dose corticosteroids, CAR-T-cell therapy, hematopoietic cell transplant [HCT], or moderate or severe primary immunodeficiency
3. Have you ever had an allergic reaction to a component of the COVID-19 vaccine, including polyethylene glycol (PEG) or polysorbate or a previous dose of COVID-19 vaccine?
Questionnaire for Immunization: 4. Do you feel sick today?
5. Do you have an allergy to medications, foods, or any vaccines (eg. eggs, gelatin, thimerosal, neomycin, gentamicin, latex, aluminum, preservatives, baker's yeast, etc.)?
6. Do you have a bleeding disorder or are you taking a blood thinner?
7. Have you received COVID-19 monoclonal antibodies or convalescent plasma in the last 90 days?
8. Have you ever had a serious reaction or fainted after receiving any vaccination? (For example, a reaction for which you had to be treated with epinephrine or EpiPen, or had to go to the hospital)
9. Have you ever had a seizure, brain disorder, Bell's Palsy, or Guillain-Barre Syndrome?
10. Do you have a history of myocarditis or pericarditis?
11. Have you been diagnosed with Multisystem Inflammatory Syndrome?
12. Do you have a history of heparin-induced thrombocytopenia (HIT) or thrombosis with thrombocytopenia syndrome (TTS)
For women: Are you pregnant or are you planning on becoming pregnant during the next month?

Moderna COVID Vaccine Consent Form - Buena Vista Drug

Medicare Part B Insurance Card Information

CO Medicaid

Insurance Card Information

Uninsured