Young's Pharmacy & General Store is partnering up with the Averill Park Central School District to hold a Pfizer Covid Vaccine Clinic for FRIDAY MAY 14, 2021 between 4:30PM and 7:00PM.  

Your date is FRIDAY May 14 2021 at the: 

ALGONQUIN MIDDLE SCHOOL

(GYMNASIUM)

333 NY351 

AVERILL PARK , NEW YORK 12018

This is clinic is open to anyone who is a resident of New York State and 12 and over.  Consent from parent/guardian is required before your appointment.  We are asking a parent or guardian be present at the appointment.  

Remember the 1st dose for the clinic would be May 14, 2021 and the return date is in 3 weeks on  June 4, 2021 for dose 2.  Dose 2 will be guaranteed.  We encourage all students to not miss the date.

*****PLEASE READ*****

This Immunization Screening and Consent Form MUST BE FILLED OUT for your 1st dose of the Pfizer Covid vaccine.   THIS HELPS US REPORT TO NYS THAT YOUR CHILD HAS RECEIVED THEIR 1st DOSE OF Pfizer VACCINE.

THIS IS REQUIRED FOR EACH DOSE.  BY FILLING THIS FORM, YOU WILL ALSO SPEED UP THE VACCINATION PROCESS.

NOTE:  Completion of form to the best ability will speed up your Covid Vaccine visit.  

Please review the Emergency Use Authorization (EUA) of the Pfizer Covid-19 Vaccine.

Please review the V-Safe after vaccination health tracker. This helps the recipient report adverse effects post vaccination when they leave the facility.

DIGITAL SIGNATURE WILL BE REQUIRED BELOW THAT THE PATIENT OR PARENT/GUARDIAN HAS REVIEWED THE EUA AND V-SAFE HEALTH TRACKER. 

Thank you for your cooperation!

COVID-19 Immunization Screening and Consent Form*

Please note:  IF you answered yes to question#4, we would recommend that you stay 30 minutes post vaccination as recommended by the CDC.  Please bring your Epi-pen or Epinephrine Injection to the clinic.  If yours is expired or do not have one, we will have epinephrine injection on site.  

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.

Consent 

I have been provided and have read, or had explained to me, the information sheet about the COVID-19 vaccination. I understand that if this vaccine requires two doses, two doses of this vaccine will need to be administered (given) in order for it to be effective. I have been given an opportunity to ask questions which were answered to my satisfaction (and ensured the person named above for whom I am authorized to provide surrogate consent was also given a chance to ask questions) I understand the benefits and risks of the vaccination as described.

I request that the COVID-19 vaccination be given to me (or the person named above for whom I am authorized to make this request and provide surrogate consent I understand there will be no cost to me for this vaccine. I understand that any monies or benefits for administeringthe vaccine will be assigned and transferred to the vaccinating provider, including benefits/monies from my health insurance plan, Medicare, Medicaid or other third parties who are financially responsible for my medical care. I authorize release of all information needed (including but not limited to medical records, copies of claims and itemized bills) to verify payment and as neededfor other public health purposes, including reporting to applicable vaccine registries.

I declare that my child is 5years of age or older. I further declare that my child:

1. Has not experienced anaphylaxis (difficulty breathing) or severe allergic reactions from a previous vaccination or an injectable medication.

2. Has not had any other vaccinations in the previous 14 days (e.g. MMR, Shingrix, Varicella, or a TB skin test).

3. Is not currently sick with a fever, active respiratory infection or other moderate/s evere illness.

4. Has not received monoclonal antibodies or convalescent plasma for treatment of COVID-19 within the past ninety (90) days.

5. Is not allergic to the following ingredients in the COVID-19 vaccine: mRNA, lipi ds((4-hydroxybutyl)azanediyl)bis(hexane-6, 1-diyl)bis(2-hexyldecanoate), 2[(pol yethyleneglycol)-2000]-N, N-ditetradecyl acetamide, 1, 2-Distearoyl-sn-glycero-3-phosphocholine, and cholesterol), potassium chloride, monobasic potassium phos phate, sodium chloride, dibasic sodium phosphate dihydrate and sucrose. I understand that if my child has any of the above conditions, my child could be at increased risk of having a negative reaction or problem from the vaccine.

I further declare that if my child has any of the following conditions, I have had the opportunity to speak with my child’s primary care provider and am making an informed decision to receive the vaccine or to have my child receive the vaccine:

1. Pregnant, attempting to become pregnant or breast feeding;

2. Have a bleeding disorder or are on a blood thinner;

3. Are immunocompromised or are taking a medication that affects the immune sys tem (such as cortisone, prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn’s disease or psoriasis; HIV/AIDS, cancer, leukemia, ankylosing spondylitis or radiation treatments).

If the vaccination time is outside of a regular school day, I agree to WAIT near the clinic location for 15 minutes after receiving the vaccine. If my child has previously had a severe allergic reaction to a vaccine or injectable medication, I agree to WAIT near the clinic location for 30 minutes after receiving the vaccine. I understand that the COVID-19 vaccine is a two-part vaccine series. By si gning this consent, I am agreeing that my child will receive the first and second part of the vaccine series. I understand that the common risks associated with the COVID-19 vaccine include but are not limited to pain, redness or swelling at the site of injection, tiredness, headache, muscle pain, chills, joint pain, fever, nausea, feeli ng unwell or swollen lymph nodes (lymphadenopathy). I understand that the vaccine may cause a severe allergic reaction which can include anaphylaxis (difficulty breathi ng, swelling of the face and throat, a fast heartbeat, a rash all over the body, dizzi ness and/or weakness). I understand that these may not be all the side effects of the COVID-19 vaccine as the vaccine is approved underthe EUA. I also understand that it is not possible to predict all possible side effects or complications which could be ass ociated with the vaccine. I understand that the long-term side effects or complicati ons of this vaccine are not known at this time.  I understand that the vaccination is being given by Young's Pharmacy & General Store, LLC at the child's school. The owner and/or operator of this site, their affi liates, officers, directors, employees and agents expressly disclaim any responsibility for the vaccination. My consent is given in light of this knowledge, and in consideration of Young's Pharmacy & General Store, LLC giving the COVID-19 vaccine.  I, for myself and my heirs , administrators, trustees , executors, assigns and successors in interest do hereby agree to release and hold harmless Young's Pharmacy & General Store, LLC, affiliates, successors, assigns, officers, trustees, employees, volunteers and agents from and against any and all demands, damages, losses, costs, expenses , obligations, liabilities, claims, actions and cause of action (whether any of which is groundless or otherwise) of any nature whatsoever (including, without limitation, reasonable attorney’s fees and court costs) by reason of or resulting, in any way, from any and all acts, accidents, events , occurrences , omissions and the like rel ated to, or arising out of, directly or indirectly, my child's receipt of this COVID-19 vaccine.  Young's Pharmacy & General Store, LLC makes no warranties, express or implied, including but not limited to, implied warranties of merchantability or fitness for a particular purpos e regarding the vaccine or its effectiveness. I acknowledge receipt of Young's Pharmacy & General Store, LLC Notice of Privacy Practices.  I also consent that I understand the importance of keeping and maintaining a well child visit with my child's pediatrician or PCP.

I request that the COVID-19 vaccination be given to me (or the person named above for whom I am authorized to make this request and provide surrogate consent I understand there will be no cost to me for this vaccine. I understand that any monies or benefits for administeringthe vaccine will be assigned and transferred to the vaccinating provider, including benefits/monies from my health insurance plan, Medicare, Medicaid or other third parties who are financially responsible for my medical care. I authorize release of all information needed (including but not limited to medical records, copies of claims and itemized bills) to verify payment and as neededfor other public health purposes, including reporting to applicable vaccine registries.