Brisson Drugs Inc COVID-19 Vaccine Consent Form

COVID-19 Vaccine Consent Form

COVID-19 Vaccine is now available for everyone with a $0 co-pay, insured or un-insured! Our pharmacy is currently administering the following vaccines on these specific days:

Pfizer 12+ (1st & 2nd doses), TUESDAY & THURSDAY ONLY (In Stock Thru 9/20/22)

Pfizer 12+ Bivalent BOOSTER, Monday - Friday (In Stock starting 9/15/22)

Please fill out the form below to set up your appointment time, complete the pre-vaccination questionnaire, and agree to the consent statements.

We look forawrd to serving you soon! We appreciate you!

Select an appointment time*

Vaccine Recipient Name *

First NameLast Name

Email (If you have an email, this gives you access to the patient portal to view your vaccine record.)

example@example.com

Date of Birth

MonthDayYear

Vaccine Recipient Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

County*

Gender at birth *

Social Security Number

Medicare Beneficiary Identifier (For Medicare Patients with a Red, White, and Blue Card ONLY)

Race*

Ethnicity*

Vaccine Recipient Phone Number*

Area CodePhone Number

Mother's Maiden Name

Required for proper vaccine documentation

Primary Care Provider Name

Current Pharmacy

Emergency Contact Name*

Relationship to Emergency Contact*

Emergency Contact Phone Number*

Area CodePhone Number

Please select if you have any of the following conditions or disabilities.

COVID-19 Vaccine Screen Questions*

	Yes	No	Don't Know	Written Responses
1. How old is the person to be vaccinated?
2. Is the person to be vaccinated sick today?
3. Has the person to be vaccinated ever received a dose of COVID-19 vaccine? * If yes please write your response, which vaccine product was administered? Pfizer, Moderna, Janssen, Novavax, or other.
3a. How many dose s of COVID-19 vaccine were administered?
3b. Did you bring the vaccination record card or other documentation?
4. Is the person to be vaccinated have a health condition or undergoing treatment that makes them moderately or severely immunocompromised? (This would include, but not limited to, treatment for cancer, HIV, receipt of organ transplant, immunosuppressive therapy or high-dose corticosteroids, CAR-T-cell therapy, hematopoietic cell transplant [HCT], or moderate or severe primary immunodeficiency?
5. Is the person to be vaccinated received COVID-19 vaccine before or during hematopoietic cell transplant (HCT) or CAR-T-cell therapies?
6.Has the person to be vaccinated ever had an allergic reaction to: a component of a COVID-19 vaccine or a previous dose of COVID-19 vaccine?
7. Has the person to be vaccinated ever had an allergic reaction to another vaccines (other than COVID-19 vaccine) or an injectable medication?
8. Has the person to be vaccinated have a history of myocarditis or pericarditis?
9. Has the person to be vaccinated have a history of thrombosis with thrombocytopenia syndrome (TTS)?
10. Has the person to be vaccinated have a history of Multisystem Inflammatory Syndrome (MIS-C or MIS-A)?
11. Has the person to be vaccinated have a history of Guillain-Barre' Syndrome (GBS)?
12. Has the person to be vaccinated have history of an immune-mediated syndrome defined by thrombosis and thrombocytopenia, such as heparin-induced thrombocytopenia (HIT)?
13. Has the person to be vaccinated have a history of COVID-19 disease within the past 3 months?

Date of first dose (do not complete if you selected "no" to #3 above).

Required if you selected "Yes" to #2

Date of second dose (if applicable).

Date

Date of first booster dose (if applicable)

Date

Date of second booster dose (if applicable)

Date

Consent (check each box below after reading and prior to signing the form)*

	Check each box
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet, a copy of which I was provided at time of appointment. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent Form.
I understand that at this time, the COVID-19 vaccine requires 2 doses given 21-28 days apart depending on the manufacturer, but no more than 6 weeks apart. The new Bivalent Booster (single dose) is given 2 months after primary series or 2 months after last booster dose.
I agree to stay in the vaccine administration 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.
On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless Brisson Drugs Inc, and their staff, associates, successors, affiliates, subsidiaries, officers, directors, contractors, and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the vaccine listed above.

The vaccine is available to anyone no matter if insured or uninsured. Please check only one of the following.*

	Not Satisfied
If INSURED, check this box attesting to bringing in your prescription and medical insurance cards for your vaccine appointment. By selecting this, you are also authorizing the pharmacy to bill your insurance on your behalf for the immunization- understanding you will not incur any costs.
If UNINSURED, you must check this box to attest that the following information is true and accurate: I do not have any insurance, including but not limited to, Medicare, Medicaid, or any other private or government-funded benefit plan.

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

Please take a picture of your Driver License, Medicare Red White and Blue Card, and Insurance Card and Upload

Browse Files

Signature of Person to Receive Vaccine and EUA/VIS (or Signature of Parent/Guardian if Patient is < 18 years old):*

Clear

Date Signed*

Date

217 W Broad St Saint Pauls, NC 28384