COVID Vaccine Consent Form + Appt

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

We are expecting our updated Moderna 2023 vaccines (age 12+) by the end of the week!

Pfizer updated 2023 Monovalent (Ages 12 and older) is available!

Novavax 2022

Pediatric Moderna 2023 vaccines (6 month to 11 years) will be available soon.

Flu Vaccinations

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

Quadrivalent Flu Vaccine (6 months - 64 years of age)

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 65 years and older or immunocompromised ages 19-64)

Abrysvo (RSV vaccine for ages 60 and older)

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

Section I. Personal Information

Patient's Full Name:*

First NameLast Name

Date of Birth:*

Age:*

Gender at birth: (M: Male, F: Female, U: Other)*

MFU

Race:*

Ethnicity:*

Hispanic or LatinoNot Hispanic or LatinoUnknownPrefer not to answer

Patient Cell Phone Number:*

Please enter a valid phone number. Only enter numbers no () or dashes.

Primary Phone Number:*

Please enter a valid phone number. Only enter numbers no () or dashes.

Email*

example@example.com

Mother's Maiden Name (needed to submit to vaccine registry)

Address*

AddressOne

AddressTwo

CityStateCode

ZipCountry

County you live in (for example Travis, Hays, etc.)*

Driver's license number and state of issuance*

Primary Care Doctor:

Doctor City/State:

Section II. Questionnaire for Immunization

Please select the correct option below:*

	Yes	No	Don't know or N/A
Vaccine Screening Questions: In the past two weeks, have you tested positive for COVID-19, Flu, RSV or are you currently being monitored for any of these?
Do you feel sick or have you had a new onset of fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, nausea, vomiting, or diarrhea?
Questionnaire for Immunization: Are you allergic to Polyethylene Glycol (PEG) or Polysorbate?
Do you have an allergy to medications, foods, or any vaccines (eggs, gelatin, thimerosal, neomycin, gentamicin, latex, aluminum, preservatives, baker's yeast, etc.)?
Do you carry an EpiPen?
Have you received monoclonal antibodies or convalescent plasma in the last 90 days?
Have you ever had a serious reaction or fainted after receiving any vaccination?
Have you ever had a seizure, brain disorder, or Guillain-Barre Syndrome?
Have you had any vaccinations in the past 14 days?
Are you immunocompromised or taking medications that affect your immune system?

Please specify the allergy from above:

Section III. Appointment Scheduler

Which vaccine(s) would you like to receive?*

COVID VaccineFlu Vaccine Quadrivalent (6 months - 64 years of age)Flu Vaccine High Dose/Quadrivalent (age 65 and older)Tdap (Adacel - tetanus/diptheria/pertussis)Shingles (Shingrix - 50 years and older or Immunocompromised ages 19-49)Gardasil (HPV)Hep A & Hep B (Twinrix, age 18+)Prevnar20 (Pneumonia)RSV (Abrysvo - 60 years and older)

Which COVID vaccine would you like to receive?*

Moderna Updated Monovalent 2023 (ages 12 and older) coming soon!Pfizer Updated Monovalent 2023 (ages 12 and older)Novavax (age 12+)

The pediatric Moderna bivalent booster age 6 months - 5 years is only approved for children 2 months after completing their primary series. To be eligible, they must have received Moderna for their primary series, not Pfizer. By signing below, you are acknowledging that your child has completed the Moderna primary series and is at least 2 months after their last dose.*

Clear

Please choose which dose you will be receiving:*

FirstSecondThirdBooster

Which COVID vaccine did you receive previously?*

ModernaJanssenPfizerNovavax

What was the date of your most recent COVID vaccine dose? Please provide the administration date on your vaccine card.*

Date

If scheduling your THIRD or BOOSTER dose (after a series with a COVID vaccine) please confirm which of the following statements apply to you.*

I am at least 2 months out from my primary series or booster of a COVID vaccinesI confirm that I am on immunosuppressive therapy or otherwise immunocompromisedI am 65 years of age or olderI'm a resident of a long-term care facilityI'm 50-64 years of age with an underlying medical conditionI'm 18-49 years of age with an underlying medical condition and have made an individual risk assessmentI'm 18-64 years of age and at an increased risk for COVID exposure/transmission due to an occupational or institutional setting

Appointment Scheduler*

Is the patient LESS than 18 years of age and/or unable to provide medical consent?*

YESNO

Because the patient is unable to provide medical consent, full name of parent or legal guardian* is providing authorized consent for this vaccine. Please provide your relation to the patient receiving the vaccine : (parent/legal guardian/power of attorney, etc)*

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.

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

Clear

Please choose your insurance coverage type*

Private or Third Party InsuranceMedicaidMedicareNo Insurance

Please provide your Medicaid ID Number*

Please provide your Medicare ID number found on your red, white and blue card (it should be made up of letters and numbers)*

Only enter numbers no () or dashes.

Medicare Part B Authorization : Statement to Permit Assigment of Medicare Benefits

I understand I am giving 38th Street Pharmacy permission to ask for Medicare payments for my medical care, including supplies and equipment.
I understand that Medicare needs information about me and my medical condition to make a decision about these payments. I give permission for that information to go to Medicare and the companies that handle Medicare payment requests.
I understand that the Centers for Medicare and Medicaid Services (CMS) is the government's Medicare agency. I understand that a photocopy of this release is as valid as the original document. Furthermore, I understand that I am responsible for paying any deductible or coninsurance amounts.
Therefore, I ask that payment of authorized Medicare benefits be made to either me or on my behalf to 38th Street Pharmacy for any services or items furnished to me by 38th Street Pharmacy. I authorize any holder of medical or other information about me to release such information to the Centers for Medicare & Medicaid Services (CMS) and its agents as needed to determine these benefits or benefits for related services.

Signature for Medicare Part B Authorization:*

Clear

Please take or upload pictures of front & back of pharmacy insurance card for billing purposes*

Please fill in your medical insurance ID number including alphanumeric values.

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

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.

Please pick a day and time for your vaccination (Dates available through June 7th):

J&J Appointment Scheduler

Vaccine Appointment & Consent Form