COVID-19 Vaccine Appointment Scheduling and Consent Form

COVID-19 Vaccine Consent Form

All patients age 16+ are eligible for Covid-19 vaccines in South Carolina. However, McLeskey Todd Pharmacy only administers the Johnson & Johnson vaccine which is only authorized for use in patients age 18+. The only vaccine authorized for 16-17 year old patients is the Pfizer vaccine. (Please note: If no appointments are listed that means we are full at this time. Please do not call the pharmacy to request appointments. Check back later to this form as appointments will be made available as more vaccine becomes available.)
Select an appointment time *

Vaccine Recipient Name *

First Name Middle Name Last Name
Email
example@example.com
Vaccine Recipient Physical Address *

Street Address

Street Address Line 2

City State Initials

Postal / Zip Code
Date of Birth *

Month Day Year
Gender at birth *
Race *
Ethnicity *
Vaccine Recipient Phone Number *
Mother's Maiden Name *
Required for proper vaccine documentation
Primary Care Provider Name
Emergency Contact Name *
Relationship to Emergency Contact *
Phone Number of Emergency Contact *

COVID-19 Vaccine Screen Questions *

	Yes	No
1. Are you feeling sick today?
2. Have you ever received a dose of COVID-19 Vaccine? If yes, you are not eligible to receive the Johnson & Johnson Covid-19 Vaccine.
3a. Have you ever had an allergic reaction to a component of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures?
3b. Have you ever had an allergic reaction to Polysorbate?
3c. Have you ever had an allergic reaction to a previous dose of COVID-19 Vaccine?
4. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?
5. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a component of COVID-19 vaccine, polysorbate, or any vaccine or injectable medication? This would include food, pet, environmental, or oral medication allergies.
6. Have you received any vaccine in the last 14 days? (If this answer is yes you are not eligible to receive the Covid-19 vaccine at this time.)
7. Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19? (If yes, you must have been released from the mandatory quarantine period to be eligible to receive the Covid19 vaccine at this time.)
8. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? If yes, you must wait at least 90 days post completion of treatment to be eligible to receive the Covid-19 vaccine. [note: monoclonal antibodies does not include antibiotics that you would be prescribed and filled at a pharmacy]
9. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
10. Do you have a bleeding disorder or are you taking a blood thinner?
11. Are you pregnant or breastfeeding?

Consent (check each box below after reading and prior to signing the form) *

	Check each box
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet (the Johnson & Johnson Fact Sheet is available after clicking submit), a copy of which I was provided with this Consent Form. 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 Form.
I understand that I am receiving the Johnson & Johnson COVID-19 vaccination which only requires one dose. A second dose will not be required nor administered.
I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.
I understand that I will be receiving the vaccination at no cost to me.

Employer Group Referral
The vaccine is available to anyone no matter if insured or uninsured. Please check only one of the following. *

INSURED, select this attesting to bringing in your prescription and medical insurance cards for your vaccine appointment. By selecting this, you are also authorizing the pharmacy to bill your insurance on your behalf for the immunization – understanding you will not incur any costs. UNINSURED, you must select this to attest that the 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 benefit plan.
Social Security Number (Necessary to verify eligibility status) *
Name of Insurance Company
Member ID/Medicare ID
For uninsured patients, please provide at least one of the following (please bring these with you to your appointment): Social Security Number, State Identification Number and State of Issuance, Driver's license Number and State of Issuance
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old): *

Clear
Date Signed *

Month Day Year
Date
Should be Empty:

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COVID-19 Vaccine Consent Form