COVID-19 Vaccine Screening and Consent Form

COVID-19 Vaccine Screening and Consent Form

AuBurn Pharmacy #250 - Rich Hill, MO
Section #1

Basic Patient Information
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Gender *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email *
example@example.com
Phone Number *
Please enter a valid phone number.
Primary Care Physician
Primary Care Physician Phone Number

Section #2

COVID-19 Vaccine Eligibility Screening
Please list any current health conditions *
If none, please enter N/A
Employer *
Job Title *
Insurance Coverage *
If Medicare coverage, please provide Medicare Benificiary ID Number (should include both letters and numbers) *
If uninsured or underinsured, please provide your social security number for vaccine billing purposes *
Race *

American Indian Alaskan Native Asian Black/African-American Native Hawaiian/Pacific Islander White Unknown Other
Ethnicity *

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Section #1