COVID-19 Vaccine Scheduling (J&J)
This clinic will be held at Chennell Family Wellness, 1101 N Main St McPherson, KS 67460. PLEASE BRING A PRINTED COPY OF THIS FORM WITH YOU TO YOUR APPOINTMENT.
Date of Birth
Please enter a valid phone number.
Street Address Line 2
State / Province
Postal / Zip Code
Prefer not to answer
Not Hispanic or Latino
Hispanic or Latino
Appointment Selection (Please select the same time if you live in the same household as another eligible vaccine recipient. You must come at your exact appointment time, EARLY OR LATE APPOINTMENTS ARE NOT ALLOWED)
Vaccine Screen Questions
1. Have you ever received a dose of the COVID-19 vaccine?
2. Have you ever had an allergic reaction to a component of the COVID-19 vaccine, including polysorbate?
3. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to anything else? This would include food, pet, environmental, or oral medication allergies.
4. Have you received any vaccine in the past 14 days?
5. Have you tested positive or been diagnosed with COVID-19 in the past 90 days?
6. Have you received monoclonal antibody treatment for COVID-19 in the past 90 days?
The vaccine is available to all, insured or uninsured. Please check one option:
If INSURED, check this box and share your insurance information below. By selecting this, you are also authorizing the clinic to bill your insurance on your behalf for the administration costs of the immunization – understanding you will not incur any costs.
If UNINSURED, 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. You MUST provide your drivers license number below and bring proof of ID to your appointment.
Insurance Name or Uninsured
Insurance ID Number or Drivers License # if Uninsured
For Medicare, this will be on your red, white and blue card. If you have a Medicare Advantage plan, this still needs to be your traditional Medicare number.
Consent (check each box after reading and before signing the form)
Check each box
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet (please follow the link found by hovering over the text). I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent Form.
I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.
I understand that I will be receiving the vaccination at no cost to me, but my insurance will be billed for an administration fee.
I understand that there have been extremely rare, serious blood clots in women aged 18-49 who received the Janssen vaccine, and that women aged 18-49 may want to receive a different brand of COVID-19 vaccine in which these blood clots have not been seen.
For Nurse Use:
Signature: ________________________ Site - deltoid: R L
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