COVID Vaccine Consent Form

COVID-19 Vaccine Consent Form

*Please fill out all questions below
WE HAVE JOHNSON & JOHNSON, ages 5+ BIVALENT PFIZER, AND ages 6+ MODERNA BOOSTERS AVAILABLE.

*NC BOARD OF PHARMACY WILL ONLY ALLOW US TO VACCINATE AGES 3 YEARS & UP

If you have remaining questions, please call us at (336) 790-7343.
Section I. Personal Information
Patient's Full Name:*

First NameMlLast Name
Date of Birth:*

MonthDayYear
Age (18+ only for J&J):*
Phone Number:*
Email:*
Gender:*

MaleFemale
Ethnicity:*

Hispanic or LatinoNon Hispanic/LatinoUnknownPrefer not to answer
Race:*

African AmericanAmerican IndianAsianCaucasianNative Hawaiian/Other Pacific IslanderPrefer not to answer
Address:*

Street Address Line 2
What do you need? *

First Dose (J&J only in stock)Booster (ages 5+ years in stock)
Which vaccine would you prefer? *

Johnson & Johnson (ages 18+ years only)Pfizer Booster (5+ years only)Moderna Booster (6+ years only)
If this is a booster, when was your last dose?
*must be 2 months from last dose for all boosters
Would you like to schedule an additional vaccine with this one?*

YesNo
If so, which one?*

Flu (10+)Shingles (50+)Tdap (18+)Pneumonia (18+)N/A
Would you like for us to see if your insurance will cover At Home Covid tests for free for you to pick up with your vaccine?*

YesNo
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 or are you breastfeeding?
Do you have dermal fillers?
Have you received any vaccine in the last 14 days?
Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
Do you have a bleeding disorder or are you taking a blood thinner?
Do you have a history of or a risk factor for a blood clotting disorder?

Please specify the allergy from Q2:
Please specify preferred injection site:*
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.**
Please pick a day and time for your vaccination*
Section IV. Signatures

I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) (EUA notice), 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.
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. (For Medicare patients we need the Part B information)

Browse Files

Cancelof
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 NumberState identification number and state of issuanceDriver'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.
*Please note due to the sensitivity of the vaccine if enough people do not sign up for your date we may have to reschedule appointment times. Thank you for your patience and understanding.
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COVID-19 Vaccine Consent Form