You are signing up for a Johnson & Johnson vaccine. This is one dose only. If you are in need of a second dose of a different vaccine or you do not want to receive the Johnson and Johnson single dose covid vaccine you need to exit this form and sign up at another location. If you have remaining questions, please call us at (540)434-7455.
**Vaccine supply is limited. Please keep your appointment or call if you need to cancel or change it. If you miss an appointment, no doses will be held to guarantee your dose.**
Section I. Personal Information
Section II. Questionnaire for Immunization
Section III Signatures
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Click Here for EUA, a copy of which I was provided with this Consent and Release. 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 and Release.
I have received a copy of the notice of privacy practices Click here for Privacy Practices. I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.
By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.
Vaccine Date Administered Vaccine Lot Exp Dosage Injection site
Janssen ____/____/2021 _________ __/__/2021 0.5ml R / L Arm