COVID-19 Vaccine Appointment Scheduling and Consent Form

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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

Hour MinutesAM/PM Option

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

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

Select an appointment time for a PCR Test*

Salutation

Suffix

Patient Name

First NameMiddle NameLast Name

FirstName*

LastName*

MiddleInitial*

Address*

Street Address

CityState Initials

Zip Code

DateOfBirth*

Gender*

Minimum age for vaccination at the pharmacy is 8.

RSV vaccination is only approved for patients at least 60 years of age.

Minimum age for Shingles vaccination at the pharmacy is 50 years of age.

Age

TODAYS DATE

Cell Phone Number

Please enter a valid phone number.

Primary Phone Type

Language

Drivers License State

Patient Phone Number*

Drivers License Number

SocialSecurityNumber

Email*

example@example.com

Race

Ethnicity

MothersMaidenName

Required for proper vaccine documentation

Primary Care Provider Name

Primary Care Provider Phone

Primary Care Provider Address One

Primary Care Provider Address Two

Primary Care Provider City

Primary Care Provider State

Emergency Contact Name

Primary Care Provider Zip

Employer,

HealthcareWorker

YesNo

Relationship to Emergency Contact

Phone Number of Emergency Contact

EUA/VIS: 09/21/23

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.

COVID-19 Vaccine Health Screening Questions

1. Are you feeling sick today?

YesNo

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

0.3cc

0.5cc

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 other than Influenza 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.

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

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

Insurance Type

Insurance Effective Date

ID Number

MedicareBeneficiaryIdentifier

RxBin

RxPcn

RxGroupID

Name on Insurance Card (Subscriber):

Relationship to Subscriber:

Subscriber date of birth

Date

InsuranceType2

RxBin2

RxPcn2

RxGroupID2

Relation2

InsuranceEffectiveDate2

PrescriberFirstName

PrescriberLastName

PrescriberNpi

WrittenDate

Origin

ItemNDC

Quantity

UnitOfMeasure

Refills

Directions

DispensedItemNDC

DispensedQuantity

DaysSupply

Lot

LotExpiration

PharmacistFirstName

PharmacistLastName

PharmacistNpi

DoseNumber

AdministrativeSite

AdministeredDate

AdministrationLocation

TpoCode,

FundingSource

VaccineForChildEligibility

RouteOfAdministration

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?

Screening Questions for Meningitis or TDap

	Yes	No
Is the person to be vaccinated sick today?
Does the person to be vaccinated have an allergy latex or to a component of the vaccine?
Has the person to be vaccinated ever had a serious reaction to a vaccine in the past?
Has the person to be vaccinated had brain or other nervous system problems?

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.

ReportToRegistry

YesNo

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

Medicare Advantage and Prescription Drug Plan Annual Enrollment Period (AEP) is from October 15 to December 7. During this time, you have the opportunity to switch to a new plan, which will take effect on January 1st.

Plans change their prescription pricing from year to year, and your current plan may not be the most affordable option once the new year begins. Choosing the right plan can result in significant annual savings. Best of all, we can help you find the most affordable plan, for free! While you are under no obligation to change plans, it is recommended that you evaluate all of your options to find the plan that best suits your needs.

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, we will review your medications, then print a report listing the three best choices for your 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 (if under 18)

First NameLast Name

Date Signed*

Date

Store Authorization

Email

example@example.com

vis

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