COVID-19 Vaccine Request Form

COVID-19 Vaccine Request and Appointment Form
Preferred Vaccine
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. (Update as of 01/06/22)
Dose
Due to a variety of factors, choosing a particular vaccine on this form 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.
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Important Information Regarding Boosters

At the moment, the Pfizer booster is available to all persons aged 16 and older.

At the moment, the Moderna and Johnson & Johnson boosters are available to all persons aged 18 and older.

For all eligible persons, the Pfizer or Moderna booster should be administered at least six months after your second shot.

The Johnson & Johnson (Janssen) booster should be administered at least two months after their first dose.

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Informacion Importante Sobre Dosis De Refuerzo

Ahora el dosis de refuerzo de Pfizer es aprobado para personas que tienen al menos 16 años.

Ahora los dosis de refuerzo de Moderna y Johnson & Johnson (Janssen) son aprobados para personas que tienen al menos 18 años.

Pfizer y Moderna: se administrará al menos seis meses después de completar la serie primaria.

El dosis de refuerzo de Johnson & Johnson (Janssen) se administrará al menos dos meses después de su primer dosis.

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Appointment*
Name*

First NameLast Name
Age*
Gender*

MFPrefer not to answer
Race (select all that apply)*

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Pacific IslanderWhiteUnknownOther
Ethnicity*

Hispanic or LatinoNot Hispanic or LatinoUnknown
*

HaitianNot HaitianUnknown
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
Email*
example@example.com
Do you need any assistance to get your vaccine?*

Language assistanceNo assistance neededOther
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*

MonthDayYear
Date
*

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Comments, suggestions, or special instructions
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Date

MonthDayYear
Date
Pharmacy-only Information
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 ELIGIBILITYFIREFIGHTERHEALTH CARE PERSONNELLAW ENFORCEMENTLTCF RESIDENTLTCF STAFFPHYSICIAN ORDEREDSCHOOL EMPLOYEE
Are you feeling sick today?

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

NoYes
If "Yes", who is the manufacturer?
If "Yes", when was the first dose?

MonthDayYear
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 proceduresPolysorbateA previous dose of COVID-19 VaccineAny other vaccine or injectable medicationSomething 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?

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

NoYes
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.)

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

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

NoYes
Are you pregnant or breastfeeding?

NoYes
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)

Clear
Date of Signature

MonthDayYear
Date
Vaccine
Manufacturer
NDC
Janssen (596), Moderna (807), Pfizer (592)
Dose in Series

FirstSecond (if applicable)
Injection Route
Injection Site

LDRD
Date of Dose

MonthDayYear
Date
Lot Number
Expiration

MonthDayYear
Date
Name/Signature of Certified Vaccine Administrator

Clear
Insurance
Private Insurance (071), Underinsured (072), Uninsured (073), Unspecified Eligibility (074)
Insurance Type, if applicable

MedicareMedicaid/CommercialUninsured
If Uninsured, obtain one of the following:

Social Security NumberState ID NumberDriver'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 NameLast Name
Signature

Clear
Should be Empty:

COVID-19 Vaccine Request and Appointment Form

Pharmacy-only Information