COVID-19 Vaccine Consent Form (APPOINTMENT)

Refill Pharmacy COVID-19 Vaccine Consent Form
APPOINTMENTS AT PHARMACY ONLY

HOMEBOUND PATIENTS - PLEASE CONTACT OUR PHARMACY 702-476-5888
Appointment *
Patient Name *

First Name Middle Initial Last Name
Age *
Date of Birth *

Month Day Year
Date
Gender *

M F N/A
Address *

Address

Street Address Line 2

City, State, Zip
Email address
example@example.com
Phone *

Area Code Phone Number
Emergency Contact *
Name
Emergency Contact *

Area Code Phone Number
SS# or Medicare #
Ethnicity *

Hispanic or Latino Non-Hispanic or Latino
Race *

American Indian or Alaska Native Asian Black or African American Caucasian Hispanic, Latino, or Spanish Native Hawaiian or Pacific Islander
Primary Physician Name

First Name Last Name Suffix
Physician Phone

Area Code Phone Number
Check which box(es) describes you: *

Essential Worker First Responder 65 years or older Person with a chronic condition Resident of a care facility or other group setting Under 18 years old
Medical History
Are you feeling sick today? *

YES NO
Have you already received a COVID 19 Vaccine? *

YES NO
If yes, which vaccine product?

Pfizer Moderna Janssen Other
Name of other product
Date of 1st COVID-19 Vaccine

Month Day Year
Date
Depending on availability, what is your preference? (not guaranteed) *

Moderna Janssen Pfizer Doesn't matter
Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something? For example, a reaction for which you were treated with epinephrine or EpiPen®, or for which you had to go to the hospital? *

YES NO
Are you allergic to polysorbate or polyethylene glycol? *

YES NO
Have you had immune globulin, monoclonal antibodies, convalescent serum, or a blood transfusion in the past 90 days (3 months)? *

YES NO
Have a history of myocarditis or pericarditis? *

YES NO
Diagnosed with Multisystem Inflammatory Syndrome (MIS-C or MIS-A) after a Covid 19 Infection? *

YES NO
Have a history of heparin-induced thrombocytopenia (HIT)? *

YES NO
Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies? *

YES NO
In the past 2-14 days have you experienced fever or chills, cough, shortness of breath, fatigue, muscle/ body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea? *

YES NO
Do you have a bleeding disorder or are you taking a blood thinner? *

YES NO
Are you pregnant or breastfeeding?

YES NO
Do you have dermal fillers? *

YES NO
List any drug allergies
Consent to Immunize
I reviewed a copy of the Vaccination FDA Emergency Use Authorization (EUA) and have had the opportunity to ask questions about the risks and benefits of this vaccination. *

YES NO
MODERNA COVID-19 Vaccine EUA
Janssen COVID-19 Vaccine EUA
Pfizer COVID-19 Vaccine EUA
I understand common side effects may include injection site redness, swelling, or pain, swelling of lymph nodes in arm of injection, aches or muscle pain, joint pain, fatigue, headache, shivering or chills, fever, gastrointestinal symptoms, malaise, and that the benefits include disease prevention. *

YES NO
I understand that it is recommended that I stay on location 15-30 minutes following the injection. *

YES NO
This vaccination record will be reported to the Nevada WebIZ Immunization Tracking Service. *

YES NO
I consent for the vaccination to be administered to me and for the immunizer to initiate the emergency medical plan if necessary due a reaction to the vaccination. *

YES NO
I am aware of the potential risks and side effects of the vaccine as described in the literature as well as the risk of the disease it prevents. I hereby waive any liability towards pharmacy and/or its administering employee of potential adverse effects associated with administration of the vaccine. I authorize the release of any medical or other information necessary to process the claim and I hereby assign all insurance, Medicare, Medicaid and other third-party payors’ benefits for services rendered.
Date *

Month Day Year
Date
Signature Person receiving vaccine or Parent or Guardian, if recipient is unable to sign. *

Clear
Relationship (if not the person receiving the vaccine is unable to sign)
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. (You will not be charged for the vaccine or the administration fee. We will bill a Federal program for the administration fee.) I am insured. I will upload or bring a copy of my insurance information.
File Upload

Browse Files
Insurance card or Medicare card (the vaccine is covered by the State/Federal Government and will not be charged to insurance. The administration fee will be billed to insurance.) Cancel of
File Upload

Browse Files
PHOTO ID OR PASSPORT OR OTHER FORMS OF ID Cancel of
We encourage you to download the V-Safe tool that uses text messaging and web surveys to provide personalized health check-ins after you receive a COVID-19 vaccine. Through V-Safe, you can quickly tell CDC if you have any side effects after getting the vaccine. V-Safe will also remind you to get your second COVID-19 vaccine.
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Refill Pharmacy COVID-19 Vaccine Consent Form

APPOINTMENTS AT PHARMACY ONLY

Medical History

Consent to Immunize