COVID-19 Vaccine Appointment Scheduling and Consent Form

COVID-19 Vaccine NOTICE: SECOND BOOSTER IS ONLY APPROVER FOR PATIENTS OVER 50 OR POST-ORGAN TRANSPLANT

...Moderna- First Dose ** NOT AVAILABLE **Moderna- Second Dose (First Dose received at this pharmacy) ** NOT AVAILABLE **Moderna- Second Dose (First Dose received at a different location) ** NOT AVAILABLE **Moderna- BI-VALENT BOOSTER (At least one dose received at Bayshore Pharmacy)Moderna- BI-VALENT BOOSTER (No doses received at Bayshore Pharmacy)Pfizer- First Dose ** NOT AVAILABLE **Pfizer- Second Dose (First Dose received at Bayshore Pharmacy) ** NOT AVAILABLE **Pfizer- Second Dose (First Dose received at a different location) ** NOT AVAILABLE **Pfizer- BI-VALENT BOOSTER (At least one dose received at Bayshore Pharmacy)Pfizer- BI-VALENT BOOSTER (No doses received at Bayshore Pharmacy)

PLEASE NOTE:

THE MODERNA BI-VALENT BOOSTER IS CURRENTLY OUT OF STOCK FROM THE MANUFACTURER.

YOU MAY SCHEDULE AN APPOINTMENT FOR PFIZER BOOSTERS OR WAIT UNTIL THE MODERNA BOOSTER IS AVAILABLE.

PLEASE NOTE:

WE DO NOT CURRENTLY HAVE THE

COVID VACCINE FOR PRIMARY DOSES IN STOCK.

PLEASE CONTACT THE

MONMOUTH COUNTY DEPARTMENT OF HEALTH AT

health@co.monmouth.nj.us

TO FIND A LOCATION THAT PROVIDES COVID MONOVALENT VACCINATIONS

SERVICE TYPE

Service Description

CHOOSE FROM ONE COLUMN BELOW

Self-Attestation Form for ADDITIONAL Third COVID-19 Vaccination

Self-Attestation Form for BOOSTER dose of COVID-19 Vaccination

Self-Attestation Form for Third COVID-19 Vaccination: Moderately to Severely Immunocompromised Patients

	Yes
Receiving active cancer treatment for tumors or cancers of the blood
Received an organ transplant and are taking medicine to suppress the immune system
Received a stem cell transplant within the last 2 years or are taking medicine to suppress the immune system
Moderate or severe primary immunodeficiency (such as DiGeorge syndrome, Wiskott-Aldrich syndrome)
Advanced or untreated HIV infection
Active treatment with high-dose corticosteroids (i.e., ≥20mg prednisone or equivalent per day for > 14 days) or other drugs that may suppress your immune response [e.g., alkylating agents (cyclophosphamide); antimetabolites (methotrexate); transplant-related immunosuppressive drugs (cyclosporine, tacrolimus, everolimus); TNF-blockers (etanercept)]
Other condition(s) which cause moderate or severe immunosuppression similar to the above conditions

self attest calc

self attest to immunocompromization

Days since second vaccination

Appt Date

Date

THIRD SHOT CALC

third shot confirmation

BOOSTER DOSE AND AMT

BOOSTER

PEDIATRIC

EUA

VACCINE ADMIN DATA

flu shot arrival date

Date

BOOSTER

0.5cc

BOOSTER

0.25cc

BOOSTER

We do not have that manufacturer's COVID-19 vaccine at this time. Please choose another.

Select an appointment time for a PCR Test*

APPT TIME

j&j APPT TIME

Patient Name*

First NameMiddle NameLast Name

PATIENT NAME

First NameLast Name

Address*

Street Address

CityState Initials

Zip Code

Date of Birth*

Gender at birth*

Minimum age for vaccination at the pharmacy is 8.

Age

TODAYS DATE

Patient Phone Number*

SOCIAL SECURITY NUMBER

Email*

example@example.com

Race

Ethnicity

Mother's Maiden Name

Required for proper vaccine documentation

Primary Care Provider Name

Primary Care Provider Phone

Emergency Contact Name

Relationship to Emergency Contact

Phone Number of Emergency Contact

COVID-19 Vaccine Eligibility Screening Questions

	Yes
I am a healthcare worker or Phase 1A , as defined by the State of New Jersey
I am an eligible First Responder or Phase 1B, as defined by the State of New Jersey.
I am an eligible high-risk patient with a chronic disease or Phase 1C, as defined by the State of New Jersey.
I am 55 years of age or older.
I am eligible to receive the vaccine under an authorization not listed above, as defined by the State of New Jersey.

Please bring your government-issued photo ID card, health insurance card, and proof of eligibility for vaccination.

Proof of eligibility for vaccination can include proof of age, healthcare company employee ID card, letter from healthcare employer, physician letter as proof of high-risk patient or health insurance EOB with high-risk diagnosis code.

COVID-19 Vaccine Health Screening Questions

1. Are you feeling sick today?

YesNo

As a precaution for the safety of helathcare personnel, patients with an active COVID-19 infection must wait for vaccination until the isolation time has expired.

As a precaution with moderate or severe acute illness, all vaccines should be delayed until the illness has improved.

Patients taking antibiotics for mild acute illnes are eligible to receive the vaccine.

2. Have you ever received a dose of COVID-19 Vaccine?

YesNo

How many prior doses have you received?

This dose is number:

Manufacturer for the first dose received

Required if you selected "Yes" to #2

Date of first dose

Required if you selected "Yes" to #2

Manufacturer for the second dose received

Required if you selected "Yes" to #2

Date of second dose

Required if you selected "Yes" to #2

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?

YesNo

This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.

You are not eligible to receive the COVID-19 Vaccine if you are allergic to Polyethylene glycol (PEG), please contact your Doctor.

3b. Have you ever had an allergic reaction to Polysorbate?

YesNo

This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.

While there is a coss-sensitivity possible between the PEG in Moderna vaccine and the Polysorbate in the Jannssen vaccine, patients allergic to Polyorbate are eligible to receive the vaccine.

3c. Have you ever had an allergic reaction to a previous dose of COVID-19 Vaccine?

YesNo

This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.

4. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?

YesNo

This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.

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.

YesNo

This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.

6. Have you received any vaccine in the last 14 days?

YesNo

CDC guidelines require that the COVID-19 vaccine must be administered at least 14 days apart from any other vaccine. Choose an appointment date at least 14 days after your last vaccine received, or try again at a later 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?

YesNo

8. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19 in the last 90 days? [note: monoclonal antibodies does not include antibiotics that you would be prescribed and filled at a pharmacy]

YesNo

CDC guidelines require that the COVID-19 vaccine must be administered at least 3 months after receving passive antibody therapy (monoclonal antibodies or convalescent serum). Try again at a later time.

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?

YesNo

10. Do you have a bleeding disorder or are you taking a blood thinner?

YesNo

Are you pregnant or breastfeeding?

YesNo

If you are pregnant, you may choose to be vaccinated when it’s available to you. There is currently no evidence that antibodies formed from COVID-19 vaccination cause any problem with pregnancy, including the development of the placenta.
People who are trying to become pregnant now or who plan to try in the future may receive the COVID-19 vaccine when it becomes available to them. There is no evidence that fertility problems are a side effect of any vaccine, including COVID-19 vaccines. There is no routine recommendation for taking a pregnancy test before you get a COVID-19 vaccine.

If you have questions about getting vaccinated, talking first with your healthcare provider might help you make an informed decision. If you wish to discuss this with your Doctor first, then don't make an appointment at this time. By scheduling an appointment and signing below, you acknowledge that you have read this and accept any unknown risk associated with this decision.

I have read and understand the above statement about the COVID vaccine and pregnancy.

Yes, I accept the riskNo, I do not accept risk.

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 manufacturer 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 at this time, the COVID-19 vaccine may require 2 doses given 21-28 days apart depending on the manufacturer. If this is my second dose, I will bring my vaccine card with me to be completed.
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.

I am insured with the following type of insurance:

Medicare (Traditional)Medicare (Advantage Plan)Horizon BC Of NJ or Aetna Part BOther Commercial Insurance

I am uninsured. If you are insured, checking this box may delay or cancel your requested service.

Yes

Bring your prescription and medical insurance cards with you for your vaccine appointment. You are also authorizing the pharmacy to bill your insurance on your behalf for the immunization – understanding you will not incur any costs.
Complete insurance information below.

Insurance Company

ID Number

BIN Number

Processor Control Number

Group Number

Name on Insurance Card (Subscriber):

Relationship to Subscriber:

Subscriber date of birth

Date

For uninsured patients, please select at least one of the following that you will bring with you to your appointment.

Social Security NumberState identification number and state of issuanceDriver's license number and state of issuance

Date of Influenza Vaccination (if any):

This specimen was provided voluntarily for analysis and I authorize the laboratory to process, bill and provide results. I authorize the release to my insurance carrier of any medical information necessary to process this claim, and I authorize payment of medical benefits directly to Prophase Diagnostics.
I agree to the declarations and terms in the patient acknowledgment and irrevocable assignment of benefits.I understand that if do not have insurance, I will be billed directly by Prophase Diagnostics. I also authorize release of my results to my doctor utilizing all methods of transmission according to HIPAA regulations. De- identified patient data may be used for R&D purposes.

I acknowledge that documentation to support medical necessity for all tests ordered is recorded in the patient's chart. If not signed, Authorized Healthcare Provider affirms that test orders are placed in patient file with provider signature and will be available upon request. The Office of the Inspector General requires documentation in patient medical chart including date of service, tests ordered and documentation to support medical necessity.

Date of Previous Test (if any):

Point Of Care testing at the pharmacy is available only to patients 13 years of age or older. Please reach out to your pediatrician for testing.

License Plate #

Current Medications

Separate medications with a comma. Doses are not required

Medication Allergies

Separate allergies with a comma

Past Medical History

Have you been vaccinated for COVID-19?

YesNo

Have you had an exposure to COVID-19?

YesNo

If you had an exposure, when were you exposed?

Do you have any of the following symptoms?

	Yes	No
Fever
Cough
Vomiting
Diarrhea
Shortness of Breath
Chills
Sore Throat
Muscle Pain
New Loss of Taste or Smell

Symptoms calculation

If you have symptoms, when did your symptoms start?

Do you have any of the following conditions?

	Yes	No
Asthma or Lung Disease
Diabetes
Serious Heart Condition
Pregnancy
Diseases or conditions that make it hard to cough
Extreme obesity
Kidney failure
Cirrhosis
Conditions that result in a weakened immune system including cancer treatment

Do any the choices below apply?

	Yes	No
Are you a health care worker, first responder, or law enforcement officer?
Do you live or work in a treatment facility, group home, or other group setting?
Are you a caregiver for an elderly person or someone with a weakened immune system?

Do you have any of the following symptoms?

	Yes	No
Fever
Headache
Body Aches
Sore Throat
Runny Nose
Cough
Fatigue
Head/Nasal Congestion

Symptoms calculation

List any other symptoms?

List any medications and the time of the last dose you have taken for these symptoms.

Did you receive a flu shot this season?

YesNo

Do you smoke or vape?

YesNo

Flu Testing is available to patients from 6 to 80 years of age who have been experiencing symptoms for no more than 72 hours (3 Days).

Influenza causes an increase in body temperature. If a patient does not have a fever or "feel feverish" without the use of medications to reduce fever, we will not be able to perform a test.

Please review your answers and symptoms for accuracy or contact your physician for followup.

My Products

COVID19 Rapid Test (Non-Refundable/Non-Cancellable)The test is $49.95 and by appointment only. Testing times are available as posted on the booking website. Please select the time and date carefully as there are no refunds or cancellations. This type of test may be useful if a person has exposure to someone who is suspected to be Covid-19 positive or if a person is returning from an area New Jersey has deemed to require quarantine after return.If you are testing after an exposure to an individual who is COVID19 positive that you've had close contact with, it is best practice to wait 5 days prior to testing.

$49.95

INFLUENZA A & B Rapid Test (Non-Refundable/Non-Cancellable)Flu tests are available to patients age 6 to 80 who are experiencing a coughh, fever, and possibly body aches.

$49.95

Enter coupon

Total

$0.00

Credit Card

This test has not been FDA cleared or approved; This test has been authorized by FDA under an EUA for use by authorized laboratories; This test has been authorized only for the detection of proteins from SARS-CoV-2, not for any other viruses or pathogens; and, This test is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of in vitro diagnostics for detection and/or diagnosis of COVID-19 under Section 564(b1) of the Act, 21 U.S.C. § 360bbb-3(b1 unless the authorization is terminated or revoked sooner.

This tests have not been FDA cleared or approved; This test has been authorized by FDA under an EUA for use by authorized laboratories; These tests have been authorized only for the detection of proteins from SARS-CoV-2, not for any other viruses or pathogens; and, These tests are only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of in vitro diagnostics for detection and/or diagnosis of COVID-19 under Section 564(b1) of the Act, 21 U.S.C. § 360bbb-3(b1 unless the authorization is terminated or revoked sooner. This test uses a small sample of blood from a finger stick.

Screening Questions for Influenza and Pneumonia Vaccination

	Yes	No
Is the person to be vaccinated sick today?
Does the person to be vaccinated have an allergy to eggs or to a component of the vaccine?
Has the person to be vaccinated ever had a serious reaction to influenza vaccine in the past?
Has the person to be vaccinated ever had Guilllain-Barre Syndrome?

flu/pneumonia screening calculation

Pneumonia Vaccinations are recommended for for all adults 65 years or older who have never received any pneumococcal vaccine or whose previous vaccination history is unknown:

I would also like a Pneumonia Vaccination if I am eligible.

Pneumonia requested

GENERAL VACCINE QUESTIONS

	Yes	No
Is the person to be vaccinated sick today?
Does the person to be vaccinated have allergies to medications, food, a vaccine component, or latex?
Has the person to be vaccinated ever had a serious reaction after receiving a vaccination?
Does the person to be vaccinated u have a long-term health problem with heart, lung, kidney, or metabolic disease(e.g., diabetes), asthma, a blood disorder, no spleen, complement component deficiency, a cochlear implant, or a spinal fluid leak? Are you on long-term aspirin therapy?
Does the person to be vaccinated have cancer, leukemia, HIV/AIDS, or any other immune system problem?
Does the person to be vaccinated have a parent, brother, or sister with an immune system problem?
In the past 3 months, have you taken medications that affect your immune system, such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn’s disease, or psoriasis; or have you had radiation treatments?
Has the person to be vaccinated u had a seizure or a brain or other nervous system problem?
During the past year, have you received a transfusion of blood or blood products,or been given immune (gamma) globulin or an antiviral drug?
For women: Are you pregnant or is there a chance you could become pregnant during the next month?
Have you received any vaccinations in the past 4 weeks?

Acknowledgment

I have received a copy of the Vaccine Information Sheet (back of copy) I am receiving and I have had a chance to ask questions. I understand that serious injury may result from any vaccination and in consideration of receiving the vaccination(s) checked above, voluntarily assume the risk of and accept full liability for any and all injuries and death which may occur as a result of my vaccination(s). I understand that there is no assurance that the vaccine will prevent flu or pneumonia. I understand the benefits and possible side effects of the vaccine(s) and request that the vaccine(s) be given to me.

If you would like your doctor to receive a copy of this record, what is your Doctor's name?

I have received information about the New Jersey Immunization Information System (NJIIS) and understand that the purpose of this program is to help remind me when my/my child's immunizations are due and to keep a central record of my/my child's immunization history. I understand that the medical information in the NJIIS may be shared with authorized health care providers, schools, licensed child care centers, colleges, public health agencies, health insurance companies, and others as permitted by New Jersey Law at N.J.S.A. 26:4-131 et seq. and rules at N.J.A.C. 8:57-3.I understand that I can get a copy of my/my child's record from my primary health care provider, my local health department, or the New Jersey Department of Health (NJDOH). The NJDOH may be contacted at the website or telephone number listed above. There is no cost to participate in this program.

Yes, I would like to participate in this program.No, I do not want to participate in this program.

Current Medications Not Filled At Bayshore Pharmacy

	Drug Name	Strength	Quantity per month
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
Medication 6
Medication 7

Any additional medications, information or comments

A Medicare review with Rich and Andy can provide benefit options available to you. Whether you are new to Medicare, or it's the annual open enrollment period, this review will help you navigate the confusion of Medicare enrollment.

Even if you're satisfied with your current Medicare coverage, Bayshore Pharmacy will check to see if there is another plan that will offer you better health and/or drug coverage at a more affordable price.

Before your appointment, our pharmacist will review your medications, then print a report listing the three best choices for your 2023 Medicare Part D plan based on your current medications, based on premiums, deductibles, and copays.

Your Medicare Part D review will take approximately 15 minutes.

Signature of Person to Receive Service (or Signature of Parent/Guardian if Patient is < 18 years old):

Clear

Name of Parent of Guardian

First NameLast Name

Date Signed*

Date

Store Authorization

YOU ARE NOT ELIGIBLE TO RECEIVE THIS COVID-19 VACCINE.

PLEASE REVIEW YOUR ANSWERS TO THE ELIGIBILITY QUESTIONS.

Consent Form

INSURANCE INFORMATION

PCR COVID TESTING

RAPID COVID TESTING

FLU TESTING

Credit Card

INFLUENZA/PNEUMONIA VACCINATIONS

VACCINATIONS

Medicare Part D Review

SIGNATURE