SCHROEDERS COVID-19 VACCINATION CONSENT FORM

COVID-19 VACCINATION CONSENT FORM
This COVID-19 Vaccination Consent Form is for the Schroeder Drugs in Washington, MO. If you do not have an email or would prefer to give information over the phone, please call the pharmacy at (636) 239-4707.
PATIENT INFORMATION
Name *

First Name Last Name
Email *
example@example.com
Phone *
Date of Birth *

Month Day Year
Date
Address *

Address

Street Address Line 2

City/State

Zip Code
Gender *

Male Female Other
Age *
Race *

African American American Indian Asian Caucasian Native Hawaiian/Other Pacific Islander Other Prefer not to answer
Ethnicity *

Hispanic/Latino: Non Hispanic/Latino Unknown Prefer not to answer
Emergency Contact Name *
Emergency Contact Phone Number *
Please enter a valid phone number.
Primary Care Doctor *
Primary Care Doctor's Address *
Which COVID-19 phase do you fall under? *

Phase 1A Phase 1B Phase 2 Phase 3 Unsure
What dose of COVID-19 vaccine will this be? *

First dose Second dose
If Second, Date of First Dose *

Month Day Year
Date
Which vaccine did you receive? *

Pfizer Moderna Other

INSURANCE INFORMATION
INSURANCE INFORMATION

Please complete the appropriate category.
Please indicate type of insurance *

Medicare Medicaid Private Insurance No Insurance
If you have a red, white, and blue Medicare Part B card like the sample above, the information we need is the Medicare # from the card. If you do not have your Medicare card, please call 1-800-MEDICARE.
Medicare # *
DCN # *
Insurer *
If you are an existing patient and we already have your insurance information on hand, or you do not have your insurance info available at this time, please input 0s in these fields
Subscriber ID *
Bin # *
PCN *
Group # *
*

I authorize the pharmacy to bill my insurance on my behalf for the immunization.
In order to have yourvaccine administration fee paid for by the United States Health Resources &Services Administration’s COVID-19 Program for uninsured patients, pleaseselect to provide one of the following: *

Social Security State Identification Number and State of Issuance Driver's License Number and State of Issuance
Social Security # *
State Identification # *
State of Issuance *
Driver's License # *
State of Issuance *

QUESTIONNAIRE FOR IMMUNIZATION

Please select the correct options below *

Yes

N/A

Do you feel sick today?

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?*

Have you ever had an allergic reaction to polysorbate?*

Have you ever had an allergic reaction to a previous dose of COVID-19 vaccine?*

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

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.

Have you received any vaccine in the last 14 days?

Have you ever had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?

Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?

Do you have an immunocompromising disease or have you taken medications that affect your immune system in the last three months? Such as prednisone, other steroids, anticancer drugs, drugs for rheumatoid arthritis, Crohn's disease or psoriasis, or radiation treatments.

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

FOR WOMEN: Are you breastfeeding, pregnant or considering becoming pregnant in the next 60 days?

*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.
If stated "Yes" above in regards to having ever had a positive test for COVID-19, please indicate the date you had a positive COVID-19 test.

Month Day Year
Date
Please explain any "Yes" answers provided above.

PATIENT SIGNATURES
PATIENT SIGNATURES
The Public Readiness and Emergency Preparedness Act (PREP Act) authorizes the CICP to provide benefits to certain individuals or estates of individuals who sustain a covered serious physical injury as the direct result of the administration or use of the covered countermeasures. The CICP can also provide benefits to certain survivors of individuals who die as a direct result of the administration or use of covered countermeasures identified in a PREP Act declaration. The PREP Act declaration for medical countermeasures against COVID-19 states that the covered countermeasures are any antiviral medication, any other drug, any biologic, any diagnostic, any other device, or any vaccine used to treat, diagnose, cure, prevent, or mitigate COVID-19, the transmission of SARS-CoV–2 or a virus mutating from SARS-CoV-2, or any device used in the administration of and all components and constituent materials of any such product. Information about the CICP and filing a claim is available by calling 1-855-266-2427 or visiting http://www.hrsa.gov/cicp/.

Authorization to Request Payment: I do hereby authorize Schroeder Drugs 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 that Schroeder Drugs may be required to or may voluntarily disclose my health information to my Primary Care Physician (if I have one), my insurance plan, and/or state or federal registries, for purposes of treatment, payment or other health care operations (such as administration or quality assurance

Acknowledgement of Notice of Privacy Practices: I have received a Notice of Privacy Practices. I understand that this document provides an explanation of the ways in which my health information may be used or disclosed by Schroeder Drugs and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.

Consent: I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) and V-Safe, a copy of which I was provided with this Consent and Release. I have had a chance to ask questions and had them answered to my satisfaction. I understand the benefits and risks of the vaccine requested and ask that the vaccine currently due for which I have signed below be given to me or to the person named above for whom I am authorized pursuant to Section 431.058, RSMo to make this request. ShowMeVax Reporting: This notification is being provided pursuant to § 338.010.13, RSMo. I understand and acknowledge the administration of this vaccine will be entered into the ShowMeVax system administered by the Missouri Department of Health and Senior Services unless I indicate otherwise below:
If guarantor/guardian, indicate your relationship to the recipient
Signature *

Clear
Print Name *
Date *

Month Day Year
Date

FOR PHARMACY USE ONLY
FOR PHARMACY USE ONLY
I have reviewed the Patient Information, Screening Questions, Age Guidelines, and medical conditions with the patient, if appropriate. I have also given the patient a COVID-19 vaccine information fact sheet and information on V-Safe Health Checker. Pharmacist has screened, when appropriate, for contradictions to vaccine. Pharmacist has asked that the patient stay for the appropriate amount of time after administration of vaccine.
Vaccine Manufacturer
Lot Number
Expiration Date

Month Day Year
Date
Date Given

Month Day Year
Date
Site of Intramuscular Administration

Left Deltoid Right Deltoid
Which dose is this for?

First dose Second dose
Administered By
Supervising RPh
Should be Empty:

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COVID-19 VACCINATION CONSENT FORM

PATIENT INFORMATION

INSURANCE INFORMATION

PATIENT SIGNATURES

FOR PHARMACY USE ONLY