Registration Form

COVID Vaccine Emergency List Form

This sign-up form is only for persons who wish to be on our last minute emergency call Covid Vaccination list. This does not guarantee you will receive the vaccine. However, if we have extra doses on any day we give vaccines, we will call you to offer you a vaccine. If we call you, you would need to be able to come to our office within 60 minutes. If you do not answer our phone call or you cannot make it to our office within the required time, we will move on to the next person on our list.

Have you ever received a dose of COVID-19 vaccine? *

Yes No

Sorry you are not eligible for COVID vaccine at our site
Because you have already had a COVID vaccine, you are not eligible for a vaccine at our site. If you need a 2nd dose of of the Moderna or Pfizer vaccine, you need to contact the site where you received your first dose.

Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication? (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.) *

Yes (You can still get the vaccine but you would need to be observed for 30 minutes during your appointment) No

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. *

Yes (You can still get the vaccine but you would need to be observed for 30 minutes during your appointment) No

Have you received any vaccine in the last 14 days? *

Yes No

Sorry you are not eligible for vaccine at this time
The CDC recommends that you not get the COVID vaccine within 14 days of any other vaccine. You may restart the screening process and request the COVID vaccine once it has been more than 14 days since your other type of vaccine.

Positive COVID 19 test
Have you ever had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19? *

Yes No

Has it been more then 14 days since your COVID test *

Yes No

Have all of your COVID symptoms improved? (Including fever, cough, shortness of breath) *

Yes No

Sorry you are not eligible for vaccine at this location
If it has been less than 14 days since your COVID positive test OR if you still have symptoms from COVID, we recommend you wait until you met both of these criteria prior to requesting a COVID vaccine.

Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? *

Yes No

Has it been more than 90 days since you received passive antibody therapy? *

Yes No

Sorry you are not eligible for vaccine at this time
The CDC recommends waiting at least 90 days after receiving passive antibody therapy to start the COVID vaccine series. You may request a COVID vaccine after it has been over 90 days since your treatment.

Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies? *

Yes (You can still get the vaccine but you should consult your physician) No

Do you have a bleeding disorder or are you taking a blood thinner? *

Yes (You can still get the vaccine but you should consult your physician) No

Are you pregnant or breastfeeding? *

Yes (You can still get the vaccine if you are pregnant or breastfeeding, but you should discuss the risks and benefits with your doctor) No

Do you have insurance? (Even if you do not have insurance, you are still eligible for the vaccine at no cost, however submitting to insurance helps defray our costs in providing the vaccine) *

Yes No

Insurance

If you are unable to upload your insurance card, please press the back button and click that you have "No" Insurance on the previous page, and bring your insurance card to your appointment.
Insurance Name *
Front of insurance card *

Cancel of
Back of insurance card *

Cancel of

Social Security (SSN) or Tax ID Number (TIN): Your Social Security or Tax ID number is needed because you indicated that you do not have insurance. We will submit for vaccine administration reimbursement through the HRSA uninsured program. This program requires us to have the person's Social Security or Tax ID number. If you do not have a Social Security or Tax ID number, you can enter your Driver's license or other state issued ID number.
Social Security Number *

COVID VACCINE CONSENT:
I understand that the COVID-19 vaccine is a two-part vaccine series. By signing this consent, I am agreeing that I will receive the first and second part of the vaccine series. I understand that the common risks associated with the COVID-19 vaccine include, but are not limited to, pain, redness or swelling at the site of injection, tiredness, headache, muscle pain, chills, join pain, fever, nausea, feeling unwell or swollen lymph nodes (lymphadenopathy). I understand that the vaccine may cause a severe allergic reaction which can include anaphylaxis (difficulty breathing), swelling of the face and throat, a fast heartbeat, a rash all over the body, dizziness and/or weakness. I understand that these may not be all the side effects of the COVID-19 vaccine as the vaccine is still being studies in clinical trials. I also understand that it is not possible to predict all possible side effects or complications which could be associated with the vaccine. I understand that the long term side effects or complications of this vaccine are not known at this time. I have read and understood the following documents on the Poolesville Family Practice COVID Vaccine webpage: 1. Moderna Emergency Use Authorization 2. "Facts about the COVID-19 Vaccine" 3. “What To Expect after the COVID-19 Vaccination” I also agree to WAIT near the clinic location for 15 minutes after receiving the vaccine. If I have previously had a severe allergic reaction to a vaccine or injectable medication, I agree to WAIT near the clinic location for 30 minutes after receiving the vaccine. *

I Consent

HIPAA

A federal law known as HIPAA (the Health Insurance Portability and Accountability Act) requires that medical practices and other medical providers explain to you the rules governing the privacy of your medical records. We comply with HIPAA and all local/state health privacy regulations. If you would like a copy of our official HIPAA policy it is available at the front desk or our website (poolesvillefamilypractice.com ).

Poolesville Family Practice is only contracted with Medicare (and no other private insurer)

I understand that Poolesville Family Practice is not contracted with my insurance company (except Medicare). Poolesville Family Practice will submit the bill for your vaccine administration to your insurance, but you are NOT responsible for any out of pocket expenses. If you do not have insurance, we are offering the vaccine without any charges to you.

Prescription History Access:

In order to better care for you, our doctors and staff may need to access your prescription medication history. By signing this document you give us permission to have access to your electronic prescription history.

Maryland Health Information Exchange:

We have chosen to participate in the Chesapeake Regional Information System for our Patients, Inc. (CRISP), a statewide health information exchange. As permitted by law, your health information will be shared with this exchange in order to provide faster access, better coordination of care and assist providers and public health officials in making more informed decisions. You may “opt-out” and prevent access of your health information available through CRISP by calling 1-877-952-7477 or completing and submitting an Opt-Out form to CRISP by mail, fax or through their website at www.crisphealth.org.

Immunet:

As required by the State of Maryland, we will submit your vaccine records from our office to Immunet. ImmuNet is Maryland’s Immunization Information System (IIS), a confidential and secure database that is HIPAA compliant. It stores an individual’s vaccination records, and is a web-based tool for healthcare providers and schools to keep their patients/students vaccinated on time and avoid under or over vaccination.

I agree to all of the above statements and have had all of my questions regarding the above statements answered to my satisfaction.
Name *

First Name Last Name
Signature *
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COVID Vaccine Emergency List Form

Registration Form

Sorry you are not eligible for COVID vaccine at our site

Sorry you are not eligible for vaccine at this time

Positive COVID 19 test

Sorry you are not eligible for vaccine at this location

Sorry you are not eligible for vaccine at this time

Insurance

COVID VACCINE CONSENT: