COVID Vaccine Consent Form

Section IV. Insurance/Billing Information
Chose insurance information *

Medicare Part B (select this option even if you have a Medicare Advantage plan) Colorado Medicaid Commercial Insurance Uninsured

Medicare Part B Insurance Card Information

Please input each of the following for your insurance card
Full Name (as it appears on your Medicare Part B card) *
Medicare Number *
Medicare Part B Start Date (xx/xx/xxxx) *
Authorization *

I authorize the pharmacy to bill my insurance on my behalf for the immunization

CO Medicaid

Please enter your CO Medicaid ID Number
Medicaid ID *
LETTER + SIX NUMBERS
Authorization *

I authorize the pharmacy to bill my insurance on my behalf for the immunization

Insurance Card Information

Please upload a picture or input each of the following for your insurance card
Please take or upload pictures of front & back of insurance card for billing purposes

Browse Files

Cancel of
OR
Bin number *
Six numbers on your prescription insurance card.
PCN *
Rx Group *
Identification Number *
Authorization *

I authorize the pharmacy to bill my insurance on my behalf for the immunization

Uninsured

Even if you are uninsured you are still able to receive the COVID vaccine an no cost to you.
If uninsured, you must check the box below to attest that the following information is true and accurate: *

I do not have any insurance, including but not limited to Medicare, Medicaid or any other private or government-funded health benefit plan I do have insurance (please select BACK button and chose a different option)
In order to have your vaccine administration fee paid for by the United States Health Resources & Services Administration's COVID-19 Program for uninsured patients, please select to provide one of the following: *

Social Security Number Driver's license number and state of issuance
Social Security Number *
Driver's license number and state of issuance *

Section V. Appointment Scheduler

Please read the following notices. Once you submit you will be redirected to the scheduling page to book your appointment.
*VACCINE SUPPLY IS LIMITED. PLEASE KEEP YOUR APPOINTMENT OR CALL IF YOU NEED TO CANCEL OR CHANGE IT. ADDITIONALLY, DUE TO VACCINE REQURIEMTNS; WE MAY CALL YOU TO SEE IF YOU CAN COME IN EARLIER, LATER, GO TO A DIFFERENT LOCATION OR RESCHEDULE TO A DIFFERENT DAY. IF YOU MISS AN APPOINTMENT, NO DOSES WILL BE HELD TO GUARANTEE YOUR DOSE.*

****IF YOU SCHEDULED TO RECIEVE THE VACCINE AT ANOTHER LOCATION. PLEASE CONTACT THAT ORGANIZATION TO CANCEL YOUR APPOINTMENT ONCE YOU RECEIVE YOUR FIRST DOSE AT OUR PHARMACY****
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.
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	Yes	No	Don't know or N/A
COVID-19 Screening Questions: 1. In the past two weeks, have you tested positive for COVID-19 or are you currently being monitored for COVID-19?
2. In the past two weeks, have you had a known exposure with anyone who tested positive for COVID-19?
3. Have you had a new onset of fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, nausea, vomiting, or diarrhea?
Questionnaire for Immunization: 4. Do you feel sick today?
5. Do you have an allergy to medications, foods, or any vaccines (eggs, gelatin, thimerosal, neomycin, gentamicin, latex, aluminum, preservatives, baker's yeast, etc.)?
6. Do you have a bleeding disorder or are you taking a blood thinner?
7. Have you received COVID-19 monoclonal antibodies or convalescent plasma in the last 90 days?
8. Have you ever had a serious reaction or fainted after receiving any vaccination? (For example, a reaction for which you had to be treated with epinephrine or EpiPen, or had to go to the hospital)
9. Have you ever had a seizure, brain disorder, Bell's Palsy, or Guillain-Barre Syndrome?
10. Have you received any vaccines in the last 2 weeks?
For women: Are you pregnant or are you planning on becoming pregnant during the next month?

Janssen/J&J COVID Vaccine Consent Form - Salida Pharmacy & Fountain