04/14/21 Benton County Clinic - COLLIER DRUG STORES COVID-19 VACCINE (a)

COVID-19 VACCINE IMMUNIZATION CONSENT FORM

Anyone age 16 or older is eligible to receive the vaccine.
Legal Name *

First Middle Initial Last Suffix
Last #4 SSN *
Date of Birth *

Month Day Year
Date
Gender *

Male Female
Phone *
Email
example@example.com
Street Address *
P.O. Box
Apt. No.
City *
State
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1st Dose / 2nd Dose *
Race:
White Hispanic/Latino Black/African American Native American /Alaska Native Asian Pacific Islander Other
Check if yes to the following:

Have you had a previous COVID-19 vaccine? If yes, date? Have you had any vaccines within the previous 14 days? Pfizer-BioNTech COVID-19 vaccine should be administered alone with minimal interval of 14 days before or after any other vaccine. Do you have a fever today? Are you sick today? Do you have COVID-19 infection and are currently in isolation? Are you currently in quarantine for known exposure to COVID-19? Have you ever had severe allergic reaction (anaphylactic reaction) to any vaccine, vaccine component or injectable therapy? Such as difficulty breathing, swelling of your face and throat, fast heartbeat, bad rash all over your body, dizziness and weakness. Are you pregnant, breastfeeding or planning to become pregnant? Women in this group ma y receive COVID-19 vaccine, a discussion with your healthcare provider can help make informed decision. Are you immunocompromised or have HIV, cancer, chronic kidney, lung, heart disease, sickle cell, severe obesity, do you smoke or have diabetes mellitus? Are you receiving any immunosuppressive therapy? These individuals may still receive COVID-19 vaccine unless otherwise contraindicated. Have you received monoclonal antibodies or convalescent plasma as part of COVID-19 treatment? Vaccination should be deferred for at least 90 days to avoid interference of treatment with vaccine-induced immune responses.
- NOTE: Depending on vaccine type, a second dose of COVID - 19 vaccine is due in 21 days after initial vaccine. Refer to your COVID -19 vaccination record card for second dose due date. Contact your PCP or your ADH Local Health Unit in 21 days for more information. Keep your COVID-19 vaccination record card for your records for p roof of initial vaccine date.
RELEASE AND ASSIGNMENT: The Providers Privacy Notice is available at the pharmacy.
- I have read or had explained to me the Vaccine Recipient Emergency Use Authorization (EUA) Fact Sheet for COVID - 19 vaccine risks and benef its. To read the Vaccine Recipient Emergency Use Authorization Fact Sheet for each vaccine visit the website www.cvdvaccine.com to view current EUA: or y ou may also visit the Local Health Unit or private provider t o receive a printed copy of the EUA Fact Sheet.
- I give consent to this COVID - 19 provider / staff for the individual named above to be vaccinated with COVI D - 19 vaccine.
- I hereby acknowledge that I have reviewed a copy of the P rovider’s Privacy Notice.
- I understand that information about this COVID - 19 vaccination will be included in (WebIZ) Arkansas Immunization Information Sys tem.
To My Insurance Carrier(s):
- I authorize the release of any medical information necessary to process my insurance claim(s
- I authorize and request payment of medical benefits directly to th is COVID - 19 Prov i der .
- I agree that the authorization will cover all medical services rendered until I revoke the authorization.
- I agree that the photocopy of this form may be used instead of the original.
CLINIC LOCATION:

Benton County Fairgrounds

Auditorium Building

East Entrance off Barron Rd.

7640 SW Regional Airport Blvd Rd

Bentonville, AR 72712

Questions or Cancellations please call

479-935-4316

This clinic will be offering the Pfizer vaccine. Your 2nd dose is set for 05/05/2021 at the same time/place as this appointment.
Appointment *
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COVID-19 VACCINE IMMUNIZATION CONSENT FORM

Race:

To My Insurance Carrier(s):