Lopez Island Pharmacy Vaccination Questionnaire COVID Ver 3.0

*Clinic Use ONLY-> Forehead Temp:_______F.

*****

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

Vaccination Consent Form Covid-19 Only

ONLY COMPLETE THIS FORM IF YOU HAVE AN APPOINTMENT, AND FILL IT OUT 24-72 HOURS BEFORE THAT APPOINTMENT, OR YOU WILL BE REQUIRED TO DO IT AGAIN.

rev: 02/27/2021 HIPAA Compliant ver 4.2
Do you already have an appointment date and time scheduled for a COVID-19 Vaccination? *

Yes No
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 *

Area Code Phone Number
Mobile Phone

Area Code Phone Number
Email
example@example.com
Race/Ethnicity *

Caucasian African American Hispanic Asian American Indian Pacific Islander
Preferred method of contact for second(booster) vaccinations *

Home Phone Cell Phone Email Text Message
Covid-19 Specific Vaccination Questions

Moderna Covid-19 Vaccine Patient Acknowledgment
Are you requesting a COVID-19 Vaccination: *

Yes No
Is this your first or second vaccination dose? *

1st Dose 2nd Dose
If this is your second dose, what vaccine was your first?

Moderna Pfizer Don't know
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? *

Yes No Don't Know
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
Screening Questions
In the past two weeks have you tested positive for COVID-19 *

Yes No
In the past two weeks have you had exposure to a person who tested positive for COVID-19 at a distance of six feet or less for a period of 15 or more minutes without wearing appropriate personal protective equipment? *

Yes No
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? *

Yes No
In the past 90 days have you received passive antibody therapy as part of a COVID-19 treatment? *

Yes No
Are you pregnant or breastfeeding, or do you plan to become pregnant? *

Yes No
What Trimester are you in, or breastfeeding?

1st Trimester 2nd Trimester 3rd Trimester Breastfeeding
Are you immune compromised or on a medicine that affects your immune system? *

Yes No
Do you have a bleeding disorder or are you on a blood thinner? *

Yes No
What blood thinner(s) are you taking?

Warfarin Xarelto Eliquis Pradaxa
Do you have a history of severe allergic reaction (e.g. anaphylaxis) to another vaccine or injectable medication? *

Yes No
If yes to above, what caused your allergic reaction:
Insurance Information
Have you filled a prescription at Lopez Island Pharmacy within the past 12 months and we would have your insurance information on file? *

Yes No
If we do NOT have your Insurance Information:
Insurance Company Name
Are you the primary cardholder

Yes No
If no to above what is the primary cardholders name?
Primary Cardholders date of birth:

Month Day Year
Date
Cardholder ID:
Rx Group ID:
Rx Card BIN Number:
Rx Card Card PCN Number:
Are you Medicare Eligible *

Yes No
If you are Medicare Eligible we need the Medicare ID off your Red,White&Blue ID Card. Such as 1BC2-D03-EF45.
************** It is NOT your Social Security Number *******************
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 provide (a) a valid Social Security number, or (b) state identification number and state of issuance, or (c) a driver’s license number and the state of issuance:

Yes (You do NOT have any insurance) No
If "Yes" to previous question, enter one(1) of the three(3) requested Identifications
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 will also be on our web page, www.lopezislandpharmacy.com
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

Immunization Date: ____________

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: