Madison Apothecary COVID-19 Vaccine Screening Form

COVID-19 Vaccine Consent Form

In order to receive the vaccine, you must be in the most appropriate phase of the vaccine rollout. Visit this link (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations.html) for more information at the federal level. States may have a different approach.
Do you qualify to receive the COVID-19 Vaccine as per NY State Mandate and Guidance ?*

YesNo (Fill out the form and join our waitlist/standby) We will call contact you if available.
Select an appointment time *
Vaccine Recipient Name*

First NameMiddle NameLast Name
Vaccine Recipient Physical Address*

Street Address

Apt #

CityState Initials

Zip Code
Date of Birth*

MonthDayYear
Gender at birth*
Race*
Ethnicity*
Vaccine Recipient Phone Number*
Vaccine Recipient Email*
example@example.com
Mother's Maiden Name*
Required for proper vaccine documentation
Primary Care Provider Name
Emergency Contact Name*
Relationship to Emergency Contact*
Phone Number of Emergency Contact*

COVID-19 Vaccine Screen Questions*

	Yes	No
1. Are you feeling sick today?
2. Have you ever received a dose of COVID-19 Vaccine?
3a. Have you ever had an allergic reaction to acomponent of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures?
3b. Have you ever had an allergic reaction to Polysorbate?
3c. Have you ever had an allergic reaction to a previous dose of COVID-19 Vaccine?
4. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?
5. 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.
6. Have you received any vaccine in the last 14 days?
7. Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19?
8. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? [note: monoclonal antibodies does not include antibiotics that you would be prescribed and filled at a pharmacy]
9. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
10. Do you have a bleeding disorder or are you taking a blood thinner?
11. Are you pregnant or breastfeeding?

Which arm would you like to get the injection on*

Left ArmRight Arm

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) 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 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.

Please Upload Insurance Card ( OPTIONAL )

Cancelof
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 Upload Supporting Uninsured Document ( OPTIONAL )

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

Clear
Pharmacist Name
First and Last Name
Pharmacist Signature

Clear
Immunizer Name
First and Last Name
Immunizer Signature

Clear
Lot Number
Expiration Date:
Pharmacy Name
Pharmacy NPI*
Vaccine Name :

PfizerModerna
Date Signed

MonthDayYear
Date
Should be Empty:

COVID-19 Vaccine Consent Form