COVID-19 Vaccine Registration and Consent Form (Weekend)

1

Please Select An Appointment.* This field is required.Appointment must be made at east 24 hours in advance.

2

Patient Name* This field is required.

3

Date of Birth* This field is required.

Date

4

Age* This field is required.

5

Gender* This field is required.

6

Race* This field is required.Used for reporting to State and/or Federal vaccine registries

7

Ethnicity* This field is required.Used for reporting to State and/or Federal vaccine registries

8

Address* This field is required.Number and Street

9

Address* This field is required.City

10

Address* This field is required.Sate

11

Address* This field is required.Zip

12

Email* This field is required.

example@example.com

13

Phone Number* This field is required.

Please enter a valid phone number.

14

Can we communicate with you via SMS text messages using this phone number?* This field is required.

15

Primary Care Physician Name, Phone Number and Address* This field is required.If you do not have a primary care physician, please enter N/A

16

Incase of a medical emergency, who can we contact?* This field is required.

17

What is your relationship to this emergency contact?* This field is required.

18

Emergency Contact Phone Number* This field is required.

Please enter a valid phone number.

19

Is this your FIRST or SECOND dose of the covid-19 vaccine?* This field is required.

First dose

Second dose

20

What was the date of your first dose?* This field is required.

Date

21

Do you have any allergies or have you ever had an allergic reaction to another vaccine or an injectable medication* This field is required.

Yes

No

22

Please list all the allergies or describe the allergic reaction:* This field is required.

23

Are you sick today? (For example, cold, fever, or acute illness)* This field is required.

Yes

No

24

Do you have a bleeding disorder or are you on a blood thinner?* This field is required.

Yes

No

25

Are you immunocompromised or are you on a medicine that affects your immune system?* This field is required.

Yes

No

26

Are you pregnant or plan to become pregnant in the next 45 days?* This field is required.

Yes

No

27

Are you breastfeeding?* This field is required.

Yes

No

28

Have you received any vaccine in the past 14 days?* This field is required.

Yes

No

29

Would you like to transfer your current active prescriptions to our pharmacy?* This field is required.

Yes

No

30

Have you ever had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19.* This field is required.

Yes

No

31

Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as a treatment for COVID-19?* This field is required.

Yes

No

32

Do you have dermal fillers?* This field is required.

Yes

No

33

Current Pharmacy Name* This field is required.

34

Current Pharmacy Address* This field is required.

35

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. Click J&J Vaccine, Moderna Vaccine, Pfizer Vaccine to obtain the Fact Sheet. If you have any questions, please contact us at (832) 307-1678 before your scheduled vaccine date.* This field is required.

Agree

36

I understand the COVID-19 vaccine may require 2 doses given 3-4 weeks apart. If this is my first dose of the multi-dose 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. This does not apply to the single-dose vaccines* This field is required.

Agree

37

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.* This field is required.

Agree

38

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* This field is required.

Agree

39

Which arm would you like to receive the vaccine in?* This field is required.We recommend the non-dominant arm.

Left

Right

40

Please upload a CLEAR photo of FRONT of Drivers License, State ID, or Other Government ID such as a passport* This field is required.Please ensure the the image the entire area and minimizes the background. Click the blue "Select Image" button to upload the image. Turn phone horizontal when taking the picture.

41

Please upload a CLEAR photo of BACK of Drivers License, State ID, or Other Government ID such as a passport* This field is required.Please ensure all barcodes are clearly visible. Ensure the the image the entire area and minimizes background. Click the blue "Select Image" button to upload the image. Turn phone horizontal when taking the picture.

42

Do you have Medicare?* This field is required.

YESNO

43

Please enter your Social Security Number.* This field is required.

44

Do you have health or prescription insurance?* This field is required.

YESNO

45

Please enter the BIN Number From Your Insurance CardMay appear as RxBin or just BIN and is an all numeric number usually six digits long

46

Please enter the PCN Number From Your Insurance Card

47

Please enter the Group Number From Your Insurance CardMay appear as RxGrp, Rx Group, Group, or Grp number.

48

Please enter the ID Number From Your Insurance CardMay appear as Patient ID

49

Please upload a CLEAR photo of FRONT of your INSURANCE card.* This field is required.Please ensure the the image the entire area and minimizes the background. Click the blue "Select Image" button to upload the image. Turn phone horizontal when taking the picture.

50

Please upload a CLEAR photo of BACK of your INSURANCE card.* This field is required.Please ensure the the image the entire area and minimizes the background. Click the blue "Select Image" button to upload the image. Turn phone horizontal when taking the picture.

51

If you are not the patient, what is your relationship to the patient (enter self if your are patient)* This field is required.

52

I certify that I am: (a) the patient and at least 18 years of age; (b) the parent or legal guardian of the minor patient; or (c) the legal guardian of the patient. Further, I hereby give my consent to the healthcare provider of Apteek Pharmacy, as applicable (an “applicable Provider”), to administer the vaccine(s) I have requested above. I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccine(s). I understand the risks and benefits associated with the above vaccine(s) and have received, read and/or had explained to me the Vaccine Information Statements on the vaccine(s) I have elected to receive. I also acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction. Further, I acknowledge that I have been advised to remain near the vaccination location for approximately 15 minutes after administration for observation by the administering healthcare provider. On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless the applicable Provider, its staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors, employees, and prescribers from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the vaccine(s) listed above. I acknowledge that: (a) I understand the purposes/benefits of my state’s vaccination registry (“State Registry”) and my state’s health information exchange (“State HIE”); and (b) the applicable Provider may disclose my vaccination information to the State Registry, to the State HIE, or through the State HIE to the State Registry, for purposes of public health reporting, or to my healthcare providers enrolled in the State Registry and/or State HIE for purposes of care coordination. I understand that, depending on my state’s law, I may need to specifically consent, and to the extent required by my state’s law, by signing below, I hereby do consent to the applicable Provider reporting my vaccination information to the State HIE, or through the State HIE and/or State Registry to the entities and for the purposes described in this Informed Consent form. I understand that my consent will remain in effect for four years or until I withdraw my permission and that I may withdraw my consent by providing a completed Opt-Out Form to the applicable Provider and/or my State HIE, as applicable. I understand that even if I do not consent or if I withdraw my consent, my state’s laws may permit certain disclosures of my vaccination information to or through the State HIE as required or permitted by law. I also authorize the applicable Provider to disclose my, or my child’s (or unemancipated minor for whom I am authorized to act as guardian or in loco parentis), proof of vaccination to the school where I am, or my child (or unemancipated minor for whom I am authorized to act as guardian or in loco parentis) is, a student or prospective student. I further authorize the applicable Provider to: (a) release my medical or other information, including my communicable disease (including HIV), mental health and drug/alcohol abuse information, to, or through, the State HIE to my healthcare professionals, Medicare, Medicaid, or other third-party payer as necessary to effectuate care or payment; (b) submit a claim to my insurer for the above-requested items and services; and (c) request payment of authorized benefits be made on my behalf to the applicable Provider with respect to the above-requested items and services. I further agree to be fully financially responsible for any cost-sharing amounts, including copays, coinsurance, and deductibles, for the requested items and services, as well as for any requested items and services not covered by my insurance benefits. I understand that any payment for which I am financially responsible is due at the time of service or, upon receipt of invoice if the applicable provider invoices me after the time of service. * This field is required.

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