SUNSET IN-STORE - Hawthorne Pharmacy COVID-19 Vaccine Appointment Scheduling and Consent Form

COVID-19 Vaccine Consent Form

Warning! Completing this form will allow you to schedule an appointment to receive the Moderna COVID-19 vaccine at Hawthorne Pharmacy on 2854 Sunset Blvd, West Columbia, SC 29169. If you would like to receive the vaccine at a different Hawthorne Pharmacy location, please click this link to access the store-specific form for your desired Hawthorne location. Thank you!

The Moderna COVID-19 vaccine is a 2-dose series seperated by 28 days. You will be able to sign up for the second dose during your first dose appointment.

Moderna COVID-19 vaccine Emergency Use Authorization (https://www.fda.gov/media/144638/download)

Select an appointment time*

Vaccine Recipient Name*

First NameLast Name

Vaccine Recipient Physical Address*

Street Address

Street Address Line 2

CityState

Zip Code

Date of Birth*

Gender at birth*

Race*

Ethnicity*

Vaccine Recipient Phone Number*

Mother's Maiden Name*

Required for proper vaccine documentation

Primary Care Provider (PCP) or Practice Site (if you currently do not have a PCP, please type NA)*

Emergency Contact Name*

Relationship to Emergency Contact*

Phone Number of Emergency Contact*

Have you ever had a severe allergic reaction (i.e. anaphylactic reaction) to a vaccine, medication, or food? (Yes or No)*

Because you have a history of anaphylaxis, please consult your primary care provider before receiving the COVID-19 vaccine at Hawthorne Pharmacy. Thank you!

Are you pregnant? (Yes or No)*

If you are pregnant, have you consulted you OB/GYN and been granted approval from him or her to receive the COVID-19 vaccine? (Yes or No)

Please consult your OB/GYN before scheduling a COVID-19 vaccine appointment with Hawthorne Pharmacy. Thank you!

Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? [note: monoclonal antibodies does not include antibodies that would be prescribed to you and filled at a pharmacy]

YesNo

If yes, have you received this therapy within 90 days of your scheduled appointment to receive the COVID-19 vaccine?

YesNo

The Centers for Disease Control and Prevention (CDC) recommends that individuals not receive the COVID-19 vaccine within 90 days of receiving monoclonal antibody therapy. Because of this, Hawthorne Pharmacy cannot administer the vaccine for you at this time. Thank you!

Will you have received another vaccine within 14 days of your scheduled appointment to receive the COVID-19 vaccine?

YesNo

The COVID-19 vaccine should routinely be administered alone, with a minimum interval of 14 days before or after administration of any other vaccine. Please be sure to not schedule your COVID-19 vaccine within 14 days of recieving any other vaccine.

Do you have allergies to latex, vaccines, medications, or food?

YesNo

If yes, please list all allergies here:

Are you allergic to polyethylene glycol?

YesNo

The Centers for Disease Control and Prevention (CDC) considers a history of an allergic reaction to polyethylene glycol to be a contraindication to the COVID-19 vaccine. Because of this, you cannot receive your COVID-19 vaccine at Hawthorne Pharmacy.

COVID-19 Vaccine Screen Questions*

	Yes	No
1. Are you feeling sick today?
2. Have you ever fainted or felt dizzy after receiving a vaccine?
4. Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19?
7. Do you have a weakened immune system because of HIV/AIDS or another disease that affects the immune system, long-term treatment with drugs such as high-dose steroids, or cancer treatment with radiation or drugs?
8. Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, neurologic or neuromuscular disease, liver disease, metabolic disease (e.g., diabetes), or anemia or another blood disorder?
9. Have you ever had a seizure disorder for which you are on seizure medications, a brain disorder, Guillain-Barre syndrome or other nervous system problems?

Consent (check each box below after reading and prior to 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.
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.

In which arm would you like to receive your COVID-19 vaccine?*

Left armRight arm

The vaccine is available to anyone no matter if insured or uninsured. Please select one of the following.*

INSURED: 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.UNINSURED: I do not have any insurance, including but not limited to, Medicare, Medicaid, or any other private or government-funded benefit plan.

Do you possess Medicare Part B (Medical) coverage? (Yes or No)

Please enter your name exactly as it appears on your Medicare Part B insurance card (red, white, and blue card).

Please enter your Cardholder ID for your Medicare Part B.

Because you do not have Medicare Part B coverage, we can utilize other medical insurance coverage for the COVID-19 vaccine. Please enter the following: Cardholder name for your medical insurance coverage.

Relationship to cardholder. (i.e. myself, spouse, child, etc)

Cardholder ID for your medical insurance coverage.

Please upload an image of your insurance card

For uninsured patients, please select at least one of the following that you will bring with you to your appointment.

State identification number and state of issuanceDriver's license number and state of issuance

Please enter your state identification number.

Please enter the state of issuance for you state identification card.

Please enter your driver's license number.

Please enter the state of issuance for your driver's license.

Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):*

Date Signed*

Date