Lopez Island Pharmacy Vaccination Questionnaire COVID Ver 3.0

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Lopez Island Pharmacy (360) 468-2616 Fax (360) 468-3825

Covid-19 Vaccination Consent Form

rev:07/22/2021 HIPAA Compliant ver 6.1

** Clinic Use ONLY-> Forehead Temp: ___________F.
Do you already have an appointment date and time scheduled for a COVID-19 Vaccination? *
If you do NOT have an appointment for COVID-19 vaccine do NOT fill out a consent form.

Only fill out this form if you have an appointment ALREADY scheduled.
Patient Name (Who is receiving the vaccination) *

First Name Middle Name Last Name Suffix
Birth Date: *

Month Day Year
Date
Sex at birth *

Male Female
Phone Number *
Mobile Phone
Email
example@example.com
Are you under age 65? *
Enter Employer name, if none type "None"
Race? *
Ethnicity? *
Preferred method of contact for second/booster vaccination? *

Covid-19 Specific Vaccination Questions

Moderna Covid-19 Vaccine Patient Acknowledgment
Are you requesting a COVID-19 Vaccination? *
If you are NOT wishing a COVID-19 vaccination DO NOT CONTNUE
Is this your first or second vaccination dose? *
If this is your 2nd dose, what vaccine was your 1st dose?
If this is your second dose, when did you receive your first dose:

Month Day Year
Date

Exclusion Questions

Answering yes to any of these questions may exclude you from receiving the vaccine.
Are you feeling sick today? *
Do you have a known history of a severe allergic reaction (e.g. anaphylaxis) to this vaccine or any components of the vaccine including lipids, tromethamine, tromethamine hydrochloride, acetic acid, sodium acetate, PEG(Polyethylene Glycol) and sucrose. (Full list is available in the Fact Sheet for Vaccine Recipients and Caregivers or from your health care provider.) *

Yes No
If Yes to previous question concerning allergic reactions please describe.
Have you within the past 14 days traveled via public transportation(not including ferries) , i.e. plane, train or bus? *

Yes No
Describe your travel and the length of your quarantine
Are you under the age of 18 years? *

Yes No
Have you ever received Cosmetic Fillers:? *

Yes No
If Yes to above, when did you receive the Cosmetic Fillers"

Month Day Year
Date

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

Yes (You do NOT have any insurance) No
Enter at least one of the following, you MAY enter more than one if you choose.
Social Security Number (WITHOUT DASHES ex. 123456789)
State Identification Number and State of Issuance:
Driver's License Number and State of Issuance
Enter your Drivers License Number and the State where it was issued
Is Lopez Island Medical Center your "Primary Provider"? *

Yes No
Then please enter your "Primary Care" provider name and phone number.
Enter your Primary Care provide and phone number.

Acknowledgements

I made the choice to get the COVID-19 vaccine on my own and freely. I know I have the option to refuse the vaccine. I ask that the vaccine be given to me, or to the person named above for whom I can make this request. I was given the (Fact Sheet for Vaccine Recipients and Caregivers-EUA) for this vaccine. The fact sheet has information about side effects and adverse reactions. I read or had read to me the information provided about the COVID-19 vaccine from the EUA sheet. I understand that my information will be stored electronically in the Washington Immunization and Information System (WAISS)

   I know the Food and Drug Administration (FDA) has authorized the emergency use of this vaccine. I know it is not a fully licensed FDA vaccine. I had the chance to ask questions that were answered to my satisfaction. I now know about the vaccine, alternatives, benefits, and risks, to the extent they are known and unknown at this time.

   I know that I must stay in the vaccine area or an area told to me by my health care provider after I receive my immunization so I am near my health care provider if I have any adverse reactions. If I have a history of severe allergic reaction, (e.g. anaphylaxis), I must stay for 30 minutes. If I do not have a history of severe allergic reaction, I must stay for 15 minutes

   I know that if I have a severe allergic reaction, including difficulty breathing, swelling of my face and/or throat, a fast heartbeat, a bad rash all over my body or dizziness and weakness I should call 9-1-1 or go to the nearest hospital. I know I can call my health care provider if I have any side effects that bother me or do not go away.

I was asked to join the V-SAFE program. The program does health checks on the people who get the COVID-19 vaccine. I know I should report vaccine side effects to FDA/CDC Vaccine Adverse Event Reporting System (VAERS) at 1-800-822-7967 or https://vaers.hhs.gov/reportevent.html.

   I know I must get two doses of the COVID-19 vaccine and receive the same vaccine each time. I know that with all vaccines there is no promise I will become immune (not get the virus) or that I will not have side effects. I know I may choose to not get the second dose of the vaccine. But if I do not get the second dose, the chance that I will become immune may go down.
Authorization to Request Payment:

I authorize the organization providing my vaccine to release information and request payment. I certify that the information given by me in applying for payment under Medicare or Medicaid or the HRSA COVID-19 Program for Uninsured Patients, is correct. I authorize release of all records to act on this request. I request that payment of authorized benefits be made on my behalf.

Disclosure of Records: I understand the organization providing my vaccine may be required to or may voluntarily disclose my vaccine-related health information to my primary care physician, my insurance plan, health systems and hospitals, and state or federal registries or other public health authorities, for purposes of treatment, payment or health care operations. I also understand the organization providing my vaccine will use and disclose my health information as described in its Notice of Privacy Practices which I may receive upon request or find on its website . If I am an employee of Lopez Island Pharmacy(LIP) I understand that it will keep records of this vaccination for me in Pioneer Pharmacy Database and may keep my vaccination records in LIP's Electronic Medical Records sytem employee occupational health records, to the extent required or permitted by law. Lopez Island Pharmacy does not discriminate.
Prior to your appointment you MUST watch a video from the San Juan County Health Department on your upcoming vaccination. A link to this video can be found at: https://youtu.be/6KVOtHDa4fc
After signing with your mouse or fingertip(if using a tablet or phone) don't worry how it looks, press "SUBMIT", the form will be sent electronically to us, you do NOT need to print out this form
Patient Signature *

Clear
Date *

Month Day Year
Date
Press "Submit" to finish...DO NOT PRESS "NEXT"

Forehead Temperture: ____________ F.

Lot Number: _____________ Expiration Date: ___/___/___ *

Administration Date: ___/___/___

Route: IM ONLY for Moderna

Admin Site: Left Deltoid Right Deltoid Other:________

Date this record was entered into WA Register: __________________

Notes:

Should be Empty: