COVID-19 Vaccine Request Form

Preferred Vaccine

Covid-19 Vaccines available are Johnson & Johnson (Janssen), Pfizer, and Moderna. Selecting a particular vaccine DOES NOT guarantee that it will be available for your appointment . Please call ahead of time to see which vaccine we are carrying at the moment.

Appointment *

Name *

First Name Last Name

Age *

Gender *

M F Prefer not to answer

Race (select all that apply) *

American Indian or Alaska Native Asian Black or African American Native Hawaiian or Pacific Islander White Unknown Other

Ethnicity *

Hispanic or Latino Not Hispanic or Latino Unknown

*

Haitian Not Haitian Unknown

Date of Birth *

Date

Phone Number *

Please enter a valid phone number.

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

County *

Email

example@example.com

Do you need any assistance to get your vaccine? *

Language assistance No assistance needed Other

Are you insured? *

Yes, I have insurance (private, Medicare, Medicaid, etc.). I will provide my insurance information when I schedule my appointment, and I will bring my insurance information and ID to my vaccine appointment. No, I am currently uninsured. I will provide my drivers license number, state identification card number, or social security number below, and I will bring the identification card with me to my vaccine appointment.

Identification Type, if uninsured *

ID Number, if uninsured *

Enter drivers license number, state ID number, or social security number; if you're insured, just enter "0"

Date Signed *

Date

*

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Comments, suggestions, or special instructions

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Race

Hispanic or Haitian Origin?

Yes, Hispanic AND/OR Haitian (Y); No, neither Hispanic NOR Haitian (N); Both unknown (U)

Risk Factor(s), if applicable

AGE 65+ (EXCLUDING LTCF) AGE-BASED ELIGIBILITY FIREFIGHTER HEALTH CARE PERSONNEL LAW ENFORCEMENT LTCF RESIDENT LTCF STAFF PHYSICIAN ORDERED SCHOOL EMPLOYEE

Are you feeling sick today?

No Yes

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

No Yes

If "Yes", who is the manufacturer?

If "Yes", when was the first dose?

Date

Select all (if any) of the following that you have 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 Polysorbate A previous dose of COVID-19 Vaccine Any other vaccine or injectable medication Something other than a component of the COVID-19 Vaccine, polysorbate, or any vaccine or injectable medication, including food, pet, environment, or oral medication allergies

*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.

Have you ever received any vaccine in the last 14 days?

No Yes

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

No Yes

Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? (Note: monoclonal antibodies do not include antibiotics that would be prescribed to you and filled at a pharmacy.)

No Yes

Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressant drugs or therapies?

No Yes

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

No Yes

Are you pregnant or breastfeeding?

No Yes

I request the vaccine to be given to me or the person named above, a minor for whom I represent and I am authorized to sign this consent form. I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet (https://www.fda.gov/media/146305/download), a copy of which I was provided with this consent form (online or in print). I have had a chance to ask questions that were answered to my satisfaction. I agree to stay in the vaccine adminstration 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. If insured, I authorize the pharmacy to bill my insurance on my behalf for the immunization -- understand that I will not incur any costs. If uninsured, I attest that I do not have insurance, including, but not limited to Medicare, Medicaid, or any other private or government-funded benefit plan. If uninsured, I authorize the pharmacy to use my social security number, state identification number, or driver's license number to bill the United States Health Resources & Services Administration's COVID-19 Program on behalf for immunization -- understanding that I will not incur any costs. I understand at this time, some COVID-19 vaccines require 2 doses given 21-28 days apart dependent on the manufacturer. If this is my first dose of the COVID-19 vaccine and a second dose is required (Pfizer or Moderna only), I intend to receive a second dose of the same vaccine in accordance with the timeframe specified in the Fact Sheet to complete the series.

Patient Consent/Signature (or parent/guardian, if patient is under 18)

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Date of Signature

Date

Vaccine

Manufacturer

NDC

Janssen (596), Moderna (807), Pfizer (592)

Dose in Series

First Second (if applicable)

Injection Route

Injection Site

LD RD

Date of Dose

Date

Lot Number

Expiration

Date

Name/Signature of Certified Vaccine Administrator

Clear

Insurance

Private Insurance (071), Underinsured (072), Uninsured (073), Unspecified Eligibility (074)

Insurance Type, if applicable

Medicare Medicaid/Commercial Uninsured

If Uninsured, obtain one of the following:

Social Security Number State ID Number Driver's License Number

If Uninsured, enter obtained identification number here:

If Uninsured and using State ID or Drivers License, enter state of issuance here:

If Insured, obtain insurance card:

Billing Submitted:

✓

Reported to State Immunization Information System (IIS)

✓

Notes

Pharmacist Name who reviewed this form

First Name Last Name

Signature

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COVID-19 Vaccine Request and Appointment Form

Pharmacy-only Information