Vaccine Appointment & Consent Form

 

If you have questions, please call us at 512-458-3784.

This form is HIPAA compliant and secure. Any and all information you enter will only be viewed by the staff of 38th Street Pharmacy and will only be used to process your vaccination. 

**PLEASE READ THE FOLLOWING BEFORE SCHEDULING**

You can schedule COVID, Flu, and other vaccinations with us using this form. You may schedule multiple vaccines for the same visit.

COVID Vaccinations

CDC recommends COVID-19 primary series vaccines for everyone ages 6 months and older, and COVID-19 boosters for everyone 5 years and older, if eligible. 

We routinely stock Pfizer (Comirnaty), Moderna, and Novavax.

**Infant and Toddler COVID-19 Vaccine - Note that Pharmacies are only allowed to immunize children 3 years and older without a prescription. For those younger than 3 years old, contact your pediatrician or doctors office. 

Children under the age of 3 MUST have a prescription sent to our pharmacy prior to their appointment.

• Moderna: 2 doses 4 - 8 weeks apart
• Pfizer: 3 doses - first two shots 3 - 8 weeks apart, and third dose is 8 weeks after 2nd

Booster Doses

** Due to vaccine allocations and manufacturing, vaccine appointments are due to availability and vaccine supply.  

At this time we cannot give the old formulation (monovalent mRNA vaccines) as a booster dose.

Bi-Valent Moderna Booster - age 12 and older

Bi-Valent Moderna Booster - ages 6 through 11 years

Bi-Valent Pfizer Booster - age 12 and older

Bi-Valent Pfizer Booster - age 5 through 11 years

**New Bivalent boosters are authorized for any individual age 6+ that is at least two months out from the completion of any primary COVID-19 vaccine series** 

**The pediatric Moderna bivalent booster (age 6 months - 5 years) is only approved for children 2 months after completing their primary series and they must have received Moderna 6M-5Y, not Pfizer**

 

Additional Booster Dose

COVID-19 vaccines for people who are moderately or severely immunocompromised: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/immuno.html  

Flu Vaccinations

High Dose/Adjuvanted Quadrivalent (only for ages 65 and older)

Quadrivalent Flu Vaccine (age 3 - 64)

Other Vaccinations

TDAP vaccine (tetanus, diptheria, and pertussis vaccine - needed every 10 years)

Gardasil (HPV vaccine for 9-26 year olds, 2-3 doses depending on age)

Twinrix (Hep A + Hep B vaccine for ages 18+, 3 doses)

Shingrix (shingles vaccine, 2 dose series)

Prevnar20 (pneumonia vaccine)

 

Section I. Personal Information

Section II. Questionnaire for Immunization

Section III. Appointment Scheduler

Section IV. Signatures

I hereby give my consent to 38th Street Pharmacy to administer the vaccine(s) I have requested. I certify that:

• I am (i) the patient and at least 18 years of age; (ii) the parent or guardian of the minor patient; or (iii) the legal guardian of the patient; or (iv) a person authorized under the law of another state or a court order to consent for the child OR
• The persons identified under (ii), (iii), or (iv) in the preceding sentence are unavailable and I have authority to consent to the immunization of the child because I am a (i) grandparent; (ii) adult brother or sister; (iii) adult aunt or uncle; (iv) stepparent; or (v) another adult who has actual care, control, and possession of the child and has written authorization to consent for the child from a parent, managing conservator, guardian, or other person who, under the law of another state or a court order, may consent for the child; additionally, I certify that I do not have knowledge of any express refusals or withdrawn authorizations of consent and have not been told not to give consent for the child. 

I understand that any Protected Health Information (PHI) I provide to 38th Street Pharmacy will only be used or disclosed by 38th Street Pharmacy in accordance with 38th Street Pharmacy's Health Insurance Portability and Accountability Act (HIPAA) Notice of Privacy Practices. (Click HERE to view Notice of Privacy Practices) By signing below I acknowledge receipt of such HIPAA Notices of Privacy Practices and consent to the uses and disclosures of PHI described therein. While 38th Street Pharmacy reserves the right to not do so, I consent to 38th Street Pharmacy reporting my immunization information to the State Immunization Registry. Should 38th Street Pharmacy elect to report my immunization history to the Texas central immunization registry, ImmTrac, I further understand that my immunization information may be accessed by other health care providers, educators, public health, representatives, state agencies, and certain insurance payers. I further authorize 38th Street Pharmacy to (1) release my medical or other information to my healthcare professionals, Medicare, Medicaid, or other third-party payer as necessary to effectuate care or payment or otherwise, (2) submit a claim to my insurer for the below requested items and services, and (3) request payment of authorized benefits be made on my behalf to 38th Street Pharmacy with respect to the below requested items and services.

NOT A SUBSTITUTE FOR A PHYSICIAN

I understand that 38th Street Pharmacy representatives are not physicians trained to diagnose and treat medical problems. I acknowledge that the administration of Services does not constitute and should not be interpreted as medical advice or opinions substituting for the advice of a physician. I understand that the administration of Services does not create a doctor patient relationship between myself and 38th Street Pharmacy. I agree to consult a physician if I require medical advice or services at any time.

RELEASE, IMDEMNITY AND DISCLAIMER

I understand that it is not possible to predict all possible effects or complications associated with receiving vaccines. I understand the risks and benefits associated with the vaccine(s) I've elected to receive. I also acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction. I additionally acknowledge that I have received a copy of the 38th Street Pharmacy notice of privacy. 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 health care provider. I understand that in the course of the requested vaccine administration, a 38th Street Pharmacy representative could possibly be exposed to my blood or bodily fluids. In such event, I agree to review and execute the "38th Street Pharmacy Post-exposure Consent for Testing" form.

On behalf of myself, my heirs, and personal representatives, I further hereby WAIVE, RELEASE, and AGREE TO ENDEMNIFY, DEFEND, AND HOLD HARMLESS (including costs and attorney's fees) 38th Street Pharmacy, its staff, agents, employees, and corporate affiliates from any and all liabilities or claims whether known or unknown arising out of, in connections with, or in any way related to the administration of vaccine(s) and related services, even should such damages or losses result from 38th Street Pharmacy's negligence.

If I elected to receive a COVID vaccination I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) -  View Moderna EUA by clicking here, View Pfizer Vaccine Fact Sheet here, View Novavax Fact Sheet here, or View Janssen (J&J) EUA Fact Sheet Here - a copy of which I was provided with this Consent and Release. 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 and Release.

The Vaccine Information Sheet for the flu vaccine can be found by clicking here.

By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.