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 COVID vaccination.
Section I. Personal Information
Section II. Questionnaire for Immunization
Section III. Appointment Scheduler
We will not be giving vaccines May 21st (Friday), May 31st (Monday), or the week of June 14-18th.
Your second dose of the Moderna vaccine will be due 28 days after your first. If needed you can recieve the second dose up to 4 days prior to the 28th day, but no sooner. The second dose can be given up to 6 weeks after the first dose.
If none of the available days work for you for a second dose please choose a time and then notify us closer to that date and we will work with you to get you in!
Section IV. Signatures
I hereby give my consent to 38th Street Pharmacy to administer the vaccine(s) I have requested. I certify that:
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, including the novel COVID-19 vaccines. I understand the risks and benefits associated with novel vaccine(s) and elect to receive a COVID-19 vaccine. 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 COVID-19 vaccine(s) and related services, even should such damages or losses result from 38th Street Pharmacy's negligence.
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, 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.
Medicare Part B Authorization : Statement to Permit Assigment of Medicare Benefits
In order to have your vaccine administration fee paid for by the United States Health Resources & Services Administration's COVID-19 Program for uninsured patients, please provide your Social Security Number.
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.
If you received a first dose of Pfizer or have already received the Johnson & Johnson vaccine you are not eligible to receive Moderna at this time.