Pfizer COVID-19 Immunization Consent Form- Meyer Pharmacy

This link is to schedule your Pfizer COVID-19 Immunization at Meyer Pharmacy in Waverly, Iowa.

The Pfizer vaccine is available for those age 5 or older. Please have your pharmacy insurance card and ID ready when completing this form.
Please specify whether this vaccination will be your FIRST, SECOND, or a BOOSTER dose of the COVID-19 vaccine: *

First dose Second dose Booster dose Second booster dose
Please specify which vaccine you received for your initial series: *

Pfizer Moderna Johnson & Johnson (Janssen)
You may receive a BOOSTER dose of the Pfizer COVID-19 vaccine 2 MONTHS following your Johnson & Johnson (Janssen) vaccine. Please indicate the date you received your Johnson & Johnson COVID-19 vaccine: *

Month Day Year
Date
Individuals 18 years of age or older may receive a BOOSTER dose of the Pfizer COVID-19 vaccine 5 MONTHS following your second dose of your Moderna vaccine. Please indicate the date you received your SECOND dose of the Moderna vaccine: *

Month Day Year
Date
Individuals 5 years of age or older may receive a BOOSTER dose of the Pfizer COVID-19 vaccine 5 MONTHS following the second dose of the Pfizer vaccine. Please indicate the date you received your SECOND dose of the Pfizer vaccine: *

Month Day Year
Date
Individuals 50 years of age or older may receive a SECOND BOOSTER dose of the Pfizer COVID-19 vaccine 4 MONTHS following your initial booster dose. Please indicate the date you received your INITIAL BOOSTER dose of vaccine: *

Month Day Year
Date

Please select the appropriate response regarding the first dose of Pfizer vaccine you have received: *

I received my first dose of the Pfizer COVID vaccine at Meyer Pharmacy. I received my first dose of the Pfizer COVID vaccine at another location/provider.
Your second appointment date and time should be written on the back of your Vaccination Record Card. If you have questions or a conflict with this date, please contact us at (319) 352-3120.
Please indicate the date you received your FIRST dose of the Pfizer COVID vaccine:

Month Day Year
****Please Note****

Your second dose of the Pfizer COVID vaccine should be given 3 weeks following your first dose. Please be sure to note the available dates on the next page and choose an appropriate appointment date based on this information.

COVID Vaccination Appointment

Please keep your appointment or call the pharmacy if you need to cancel or change it. To maintain social distancing guidelines, please wear a mask and come into the pharmacy PROMPTLY at your scheduled appointment time.
Please select an available appointment (date and time) to receive your COVID-19 vaccine. *
***PLEASE NOTE***

If you are scheduling your FIRST dose, your appointment for your SECOND dose will be scheduled three weeks following your first dose. Please take note of this date indicated on the back of your COVID-19 vaccination record card. Please notify the pharmacy promptly if you are unable to return to the pharmacy on this date.

Payment

There is no cost to you to receive this vaccine, but an administration fee may be billed to and covered by your insurance.
Choose a payment method *

Commercial Insurance Medicare Medicaid (Iowa Medicaid, Amerigroup or Iowa Total Care) I don't have insurance coverage.
Please specify your Medicaid provider: *
Please enter your Medicaid ID number as it appears on your card: *

Insurance Card Information

Please input the following from your insurance card.
Rx Bin number *
PCN
Identification Number *
Rx Group *
Medicare ID: *
Please enter your Medicare identification number as it appears on your Medicare Card

Fact Sheet for Vaccine Recipients and Caregivers

Please click on the link below to read the Emergency Use Authorization (EUA) of the Pfizer COVID-19 Vaccine and complete the acknowledgement statement after reading the document. A printed copy of this information will be available at the pharmacy upon request.
Fact Sheet for Recipients and Caregivers of the Pfizer COVID-19 Vaccine
Please check below to acknowledge you have read the EUA fact sheet for the Pfizer COVID-19 Vaccine. *

Yes, I have read the information provided above.

	Yes	No	Don't know or N/A
Do you have any allergies to any of the Pfizer COVID-19 vaccine components listed in the fact sheet?
Have you ever had a serious allergic reaction (e.g., anaphylaxis) to something? For example, a reaction for which you were treated with epinephrine or EpiPen, or for which you had to go to the hospital?
Do you have a bleeding disorder or are you taking a blood thinner?
Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
Have you ever tested positive for COVID-19 or has a doctor ever told you that you had COVID-19?
Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as a treatment for COVID-19?
For women: Are you pregnant or breastfeeding

This link is to schedule your Pfizer COVID-19 Immunization at Meyer Pharmacy in Waverly, Iowa.