COVID Vaccine Consent Form

COVID Vaccine UNIVERSAL FORM

Please fill out this Immunization Screening and Consent Form for your 1st dose of the Moderna Covid vaccine. NOTE: Completion of this form to the best of your ability will speed up your Covid Vaccine visit. Read this form entirely and fill out the required details below. This form is HIPAA Compliant.
Emergency Use Authorization

The FDA has made the COVID-19 vaccine available under an emergency use authorization(EUA). The EUA is used when circumstances exist to justify the emergency use of drugs and biological products during an emergency, such as the COVID-19 pandemic. This vaccine has not completed the same type of review as an FDA-approved or cleared product. However, the FDA's decision to make the vaccine available under an EUA is based on the existence of a public health emergency and the totality of scientific evidence available, showing that known and potential benefits of the vaccine outweigh the known and potential risks.
MODERNA VACCINE CLINICS

TUESDAYS, WEDNESDAYS, THURSDAYS STARTING OCTOBER 26TH,2021

AT

WASHINGTONVILLE PHARMACY

This VACCINE is currently BY APPOINTMENT ONLY reserved for patients 18 and over who meet certain criteria.

After completion, you will get a confirmation email.

If you have any difficulties, please try a new browser (or incognito mode in your current browser), or try to resubmit.

If you have questions, please email vaccinewashingtonville@gmail.com. Please do not call the store.
Are you 18 years of age or older ?*

YesNo
What dose of COVID vaccine will this be?*

FirstSecondAdditional dose due to immunocompromised
You are not eligible for this clinic.

This clinic is for patients 18 or older.
Section I. Personal Information
Patient First Name*
Patient Last Name*
Please enter your Date of Birth*

MonthDayYear
Date
Legal Gender:*

MaleFemaleTransgenderPrefer Not to Answer
Ethnicity:*

Decline to AnswerNon-Hispanic OriginHispanic OriginUnknown
Race:*

DeclineNative American or AlaskanAfrican American or BlackNative Hawaiian or Pacific IslanderWhiteAsianOther or MultiracialDecline to Answer
Phone Number (10 digits no dashes or spaces):*
Email*

Confirmation Emailexample@example.com
Address:*

Street Address Line 2
Primary Care Doctor:*
Doctor City/State:*
Please enter any and all drug or food allergies:
Section II. Questionnaire for Immunization

Please note: IF you answered yes to question#2 or #3, we would recommend that you stay 30 minutes post vaccination as recommended by the CDC. Please bring your Epipen or Epinephrine Injection to the clinic. If yours is expired or do not have one, we will have epinephrine injection on site.
Section III. Insurance Information

****IT IS VERY IMPORTANT THAT YOU PROVIDE THE INSURANCE INFORMATION ON THIS FORM TO PREVENT DELAYS AT THE TIME OF SCHEDULED VACCINATION****
ID Number Prescription Card or Medicare ID Number (Not Social Security #)
Group Number Prescription Card (Rx Group if Different)
BIN Number Prescription Card
PCN Number Prescription Card
Please bring a copy of your prescription card along with ID to the vaccination site
Section IV. Signatures

In an attempt to reduce paper waste, all legally required documents must be downloaded here. Very limited copies will be available on clinic day.

Click this to download the Emergency Use Authorization for the Moderna Vaccine.

Click this to download the Notice of Privacy Practices

Click this to download the CDC vSafe app flyer

I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA), a copy of which I was provided with this registration.

I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.

I certify that I have received, read, and understand the Emergency Use Authorization.

I certify that I have received the Notice of Privacy Practices.

I certify that I have received the CDC vSafe informational flyer.

I certify I am at least 18 years of age. (ID will be required)

I understand this appointment is for the Moderna vaccine.

Please type your full name in the box below. You agree your typed full name represents your electronic signature is the legal equivalent of your manual signature on this form.
Type Your Full Name as Electronic Signature*
Insurance Billing for the Administration of the Vaccine

I authorize the pharmacy to bill my insurance on my behalf for the immunization
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
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 select to provide one of the following:*

Social Security NumberState identification number and state of issuanceDriver's license number and state of issuance
Social Security Number*
State identification number and state of issuance*
Driver's license number and state of issuance*
Section IV. Appointment Confirmation

THE SECOND DOSE OF THE MODERNA VACCINE WILL BE FOUR WEEKS LATER.

**Vaccine supply is limited. Please keep your appointment.**

Additionally, due to vaccine requirements; we may call you to see if you can come earlier, later or to a nearby location.

If you miss an appointment, no doses will be held to guarantee your dose in the future.
Choose Your Appointment Time: We are accepting 4 people every 15 minutes.*
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.
Should be Empty:

	Yes	No	Don't know or N/A
COVID-19 Screening Questions: In the past two weeks, have you tested positive for COVID-19 or are you currently being monitored for COVID-19?
In the past two weeks, have you had a known exposure with anyone who tested positive for COVID-19?
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: 1. Do you feel sick today?
2. Have you ever had a serious or life-threatening allergic reaction (hives, difficulty breathing) to any vaccine or shot?
3. Do you carry an EpiPen?

COVID Vaccine UNIVERSAL FORM

Emergency Use Authorization

Section I. Personal Information

Section II. Questionnaire for Immunization

Please note: IF you answered yes to question#2 or #3, we would recommend that you stay 30 minutes post vaccination as recommended by the CDC. Please bring your Epipen or Epinephrine Injection to the clinic. If yours is expired or do not have one, we will have epinephrine injection on site.

Section III. Insurance Information

Please bring a copy of your prescription card along with ID to the vaccination site

Section IV. Signatures

Section IV. Appointment Confirmation