This section MUST be completed in its entirety. Centennial Pharmacy Services cannot provide you with a COVID-19 Vaccination without this information.
Commercial Insurance Information
NOTE: Medicare is required for all patients 65 and older, or Medicare Elgible.
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 either (a) a valid social security number (*preferred), (b) state identification number and state of issuance, OR (c) a driver’s license number and the state of issuance.
Please note: Completing this form does not guarantee you the COVID-19 vaccination. The vaccination is allocated per the Federal Government, Pennsylvania State Department of Health, and Philadelphia Department of Public Health. This survey is a place holder to schedule a vaccination when the state allocates vaccinations to Centennial Pharmacy Services in your Phase. If you are not notified to schedule right away, when your vaccine is available, Centennial will contact you to schedule your vaccination. Always consult with your healthcare provider to identify if the COVID-19 vaccination is right for you, or if you have any conditions that may preclude receiving the vaccine.
1 I agree to WAIT at the designated location for 15 minutes after receiving the vaccine. If I have previously had a severe allergic reaction to a vaccine or injectable medication, I agree to WAIT at the designated location for 30 minutes after receiving the vaccine.
2 I understand that the COVID-19 vaccine is a two-part vaccine series. By signing this consent, I am agreeing that I will receive the first and second part of the vaccine series, unless my primary care provider and/or other provider tells me otherwise.
3 I understand that the common risks associated with the COVID-19 vaccine include but are not limited to pain, redness or swelling at the site of injection, tiredness, headache, muscle pain, chills, joint pain, fever, nausea, feeling unwell or swollen lymph nodes (lymphadenopathy). I understand that the vaccine may cause a severe allergic reaction which can include anaphylaxis (difficulty breathing, swelling of the face and throat, a fast heartbeat, a rash all over the body, dizziness and/or weakness). I understand that these may not be all the side effects of the COVID-19 vaccine as the vaccine is still being studied in clinical trials. I also understand that it is not possible to predict all possible side effects or complications which could be associated with the vaccine. I understand that the long-term side effects or complications of this vaccine are not known at this time.
4 I understand that the vaccination is being given by Centennial Pharmacy Services, Incorporated (Centennial) and its affiliates (collectively Centennial). The owner/operator of your chosen clinic site, their affiliates, officers, directors, employees, volunteers, and agents expressly disclaim any responsibility for the vaccination. My consent is given in light of this knowledge, and in consideration of Centennial giving the COVID-19 vaccine. I, for myself and my heirs, administrators, trustees, executors, assigns and successors in interest do hereby agree to release and hold harmless Centennial Pharmacy Services, Incorporated, its subsidiaries, divisions, affiliates, successors, assigns, officers, trustees, employees, volunteers and agents from and against any and all demands, damages, losses, costs, expenses, obligations, liabilities, claims, actions and cause of action (whether any of which is groundless or otherwise) of any nature whatsoever (including, without limitation, reasonable attorney’s fees and court costs) by reason of or resulting, in any way, from any and all acts, accidents, events, occurrences, omissions and the like related to, or arising out of, directly or indirectly, my receipt of this COVID-19 vaccine. Centennial makes no warranties, express or implied, including but not limited to, implied warranties of merchantability or fitness for a particular purpose regarding the vaccine or its effectiveness. I acknowledge receipt of Centennial’s Notice of Privacy Practices.
5 I have received the Vaccine Information Sheet(s), Emergency Use Authorization Fact Sheet(s), and/or patient fact sheet corresponding to the COVID-19 Vaccination I am going to receive. I further understand and agree that Centennial is required to submit COVID-19 vaccine administration data to the Pennsylvania Immunization Information System (PA-SIIS), Philadelphia Immunization Information System (PhilaVAX), and report moderate and severe adverse events following vaccination to the Vaccine Adverse Event Reporting System (VAERS).
6 I understand and agree to all of the above and I hereby give my consent to the staff of Centennial Pharmacy Services, Incorporated to give me a COVID-19 vaccine.
7 If I am receiving a vaccine through a vaccine clinic, I understand that my name, and vaccine appointment date and time may be provided to the clinic coordinator.