COVID-19 Vaccine Appointment & Consent Form (Pfizer)
Appointment
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Consent Form
Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Note: Pfizer is the only COVID vaccine currently approved for children aged 16 and older.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Gender
*
Please Select
Male
Female
Prefer Not to Say
Race
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
Caucasian
Hispanic
Other
Mother's Maiden Name
*
Required for proper vaccine documentation
Allergies
Primary Care Provider Name
Emergency Contact Name
*
Relationship to Emergency Contact
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
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COVID-19 Vaccine Questions
COVID-19 Vaccine Dose
*
Pfizer First Dose
Pfizer Second Dose
Date of First Dose (only complete if receiving second dose)
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Month
-
Day
Year
Location of First Dose
*
Gwinnett Drugs
Other
COVID-19 Screening Questions
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Yes
No
1. Are you feeling sick today?
2. Have you ever received a dose of COVID-19 Vaccine?
3a. 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 and preparations for colonoscopy procedures?
3b. Have you ever had an allergic reaction to
Polysorbate?
3c. Have you ever had an allergic reaction to a previous dose of COVID-19 Vaccine?
4. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?
5. 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.
6. Have you received any vaccine in the last 14 days?
7. Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19?
8. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?
[note: monoclonal antibodies does not include antibiotics that you would be prescribed and filled at a pharmacy]
9. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
10. Do you have a bleeding disorder or are you taking a blood thinner?
11. Are you pregnant or breastfeeding?
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Insurance Questionnaire
Please check only one of the following:
*
I HAVE INSURANCE, check this box attesting to completing the medical insurance information below. By selecting this, you are also authorizing the pharmacy to bill your insurance on your behalf for the immunization – understanding you will not incur any costs.
I DO NOT HAVE INSURANCE, you must check this box to attest that the 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 benefit plan.
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Insurance Information
Insurance Company Name
*
Policy #
*
Group #
*
ID #
*
Medicare ID Number (from red white & blue card, if applicable)
Prescription Drug Plan Name
RxBIN
RxPCN
RxGroup
ID #
Upload a Copy of your Insurance Card
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To escalate your appointment, please upload a picture of your insurance card.
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Required Information
Social Security Number
*
Type 0 you do not have a SSN & Enter Phone Number Below
Phone Number
Please enter a valid phone number.
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Consent
I have read, or have had read to me, the written information regarding the vaccine(s) being administered. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s) being administered and have received a copy of a current Vaccine Information Sheet. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Gwinnett Drugs, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s). I certify that I am at least 18 years old and hereby give my consent to the pharmacists of Gwinnett Drugs to administer the vaccine(s). If under 18 years old signature by parent or guardian is required. I agree to wait near the vaccination location for approximately 15 minutes for observation by the pharmacist.
HIPAA Privacy Information & Medical Records
(1) I have acknowledged that I have received the providers Notice of Privacy Practices which may be provided at my request. (2) For Medicare, Medicaid, or Insurance Billing: I authorize this provider to release information and request payment. I understand that the information given by me in applying for payment is correct. (3) I authorize the release of all records to act on this request and I request that the payment of benefits be made on my behalf.
Acknowledgement
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I consent to the above and acknowledge the HIPAA Privacy Information & Medical Records
Signature
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Submit
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