COVID-19 Vaccine Consent Form

COVID-19 Vaccination Consent Form

The Medicine Shoppe Pharmacy - Lancaster is vaccinating with the Johnson & Johnson 1 dose COVID-19 vaccine.

If you do not have an email or would prefer to give information over the phone, please call the pharmacy at (740) 653-7779. After submitting this form, you will be redirected to a second form to schedule your appointment; you will also receive a link via email. If you do not complete the second form, we cannot guarantee that we will have a vaccine available for you.

Please only complete this form if you qualify for a COVID-19 vaccine in the state of Ohio. For more information, view Ohio's distribution phases here.

Section 1: Patient/Employee Information

First Name Last Name

Please click here to review Ohio's COVID-19 vaccine distribution phases and complete the following questions.

If you are not eligible for a COVID-19 vaccine in the state of Ohio, you are unable to schedule a vaccination appointment at this time.

Address

Street Address Line 2

City State

Zip

Primary Care Physician

Address

Street Address Line 2

City State

Zip

Primary Care Physician

Pfizer Moderna Johnson & Johnson Other

Section 2: Screening Questions

	Yes	No	Don't Know or N/A
In the past two weeks, have you had a known exposure with anyone who tested positive for COVID-19?
Have you had a new onset of fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headaches, new loss of taste or smell, sore throat, nausea, vomiting, or diarrhea?
Are you feeling sick today?
Have you ever had an allergic reaction* to a component of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives & preparations for colonoscopy procedures?
Have you ever had an allergic reaction* to polysorbate?
Have you ever had an allergic reaction* to a previous dose of COVID-19 vaccine?
Have you ever had an allergic reaction* to another vaccine (other than COVID-19 vaccine) or an injectable medication?
Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a component of COVID-19 vaccine, or any vaccine or injectable medication? This would include food, pet, venom, environmental, or oral medication allergies.
Do you carry an EpiPen®?
Have you received any vaccine in the last 14 days?
Have you ever had a positive test 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 treatment for COVID-19?
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 had a seizure, brain disorder, or Guillain-Barre Syndrome?
Do you have a bleeding disorder or are you taking a blood thinner?
For women: Are you pregnant or breastfeeding, or are you planning to become pregnant in the next month?
Have you ever had an allergic reaction* to a vaccine or injectable therapy that contains multiple components, one of which is a COVID-19 vaccine component, but is not know which component elicited the immediate reaction
Do you have dermal fillers?

*This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.

I have been given a copy and have read, or have had explained to me, the information in the Fact Sheet for the COVID-19 vaccine. I understand the FDA has authorized the emergency use of the COVID-19 vaccine, which is not an FDA-approved vaccine. I have had the chance to ask questions that were answered to my satisfaction.

I understand the significant known and potential risks and benefits of the COVID-19 vaccine as explained in the Fact Sheet and that some potential risks and benefits may remain unknown, and I REQUEST THE COVID-19 VACCINE BE GIVEN TO ME.

I understand the Pfizer and Moderna COVID-19 vaccines require 2 doses. If this is my first dose of the Pfizer or Moderna COVID-19 vaccine, I intend to receive a second dose of the same vaccine in accordance with the timeframe specified in the Fact Sheet to complete the vaccination series.

I agree to stay in the vaccine administration area for fifteen (15) minutes (or longer if indicated by the vaccine administrator) after receiving my vaccination to ensure that no immediate adverse reactions occur, and I understand that if I experience any adverse reaction, it will be my responsibility to follow up with my primary care physician

I have received a copy of the notice of 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.

For Pharmacy Use Only

Section 4: Vaccination Record

I have reviewed Patient Information and Questionnaire for Immunization with the patient prior to administering the vaccine, and they have indicated that all answers are accurate as of the day of administration.

IM - L Arm IM - R Arm

Personal Information