Moderna Vaccine Appointment and Consent Form
Citizens Pharmacy
Select an appointment
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Consent Form
Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County of Residence
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Gender
*
Please Select
Male
Female
Race
*
Please Select
American Indian or Alaska Native
White
Black or African American
Hispanic or Latino
Asian
Native Hawaiian or Other Pacific Islander
Other
Mother's Maiden Name
*
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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What dose of the COVID-19 Vaccine are you receiving?
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First Dose
Second Dose
Booster (Bivalent)
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 Information
Please select one of the following
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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
Medical Insurance Company Name
*
ID #
*
Group #
*
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Social Security 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 and EUA statement. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Citizens Pharmacy, 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 Citizens Pharmacy 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
*
I consent to the above and acknowledge the HIPAA Privacy Information & Medical Records
Signature
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Clear
Submit
Administration
(Pharmacist Use Only)
Lot
Site of Injection
Immunizer Name
Should be Empty: