Vaccine Form Mariana Bracetti Academy Charter

1840 Torresdale Ave, Philadelphia, PA 19124

Which vaccine are you interested in today?

Moderna COVID (1st/ 2nd dose)Moderna COVID Bivalent (Booster ages 18 yrs+)Pfizer COVID (1st/ 2nd dose)Pfizer COVID Bivalent (Booster ages 12 yrs+)Fluad (Flu vaccine 65+)Flu vaccine (ages 19+)

Name*

First NameLast Name

Date of Birth*

Age*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Phone Number*

Please enter a valid phone number.

Gender:*

MaleFemale

Ethnicity:*

Hispanic or LatinoNot Hispanic or LatinoUnknown

Race:*

Are you sick today?*

YesNo

Do you have long term health problem with heart disease, kidney disease, metabolic disorder (diabetes), anemia or other blood disorders?*

YesNoNot sure

Do you have a long term health problem with lung disease or asthma? Do you smoke?*

YesNoNot sure

Do you have allergies to medications, food (i.e. eggs), latex or anyvaccine component (e.g. neomycin, formaldehyde, gentamicin,thimerosal, bovine protein, phenol, polymyxin, gelatin, baker’s yeastor yeast)?*

YesNoNot sure

Have you received any vaccinations in the past 4 weeks?*

YesNoNot sure

Have you ever had a serious reaction after receiving a vaccination?*

YesNoNot sure

Have you ever fainted or felt dizzy after a vaccine?*

YesNo

Do you have a neurological disorder such as seizures or otherdisorders that affect the brain or have had a disorder that resultedfrom a vaccine (e.g. Guillain-Barre Syndrome)?*

YesNoNot sure

Do you have cancer, leukemia, AIDS, or any other immune systemproblem? (in some circumstances you may be referred to yourphysician)*

YesNoNot sure

Do you take prednisone, other steroids, or anticancer drugs, or haveyou had radiation treatments?*

YesNoNot sure

For women: Are you pregnant or could you become pregnant in thenext three months?

YesNoNot sure

Medicare B or Prescription insurance card or Fill out below

RxBin# blanks RxPCN# blank RxID#
RxGroup#

Appointment*

I authorize the release of any medical or other information with respect to this vaccine to my healthcare providers, Medicare, Medicaid or other third party payer as needed and request payment of authorized benefits to be made on my behalf to Care Trust. I acknowledge that if my insurance does not cover the cost of administering the vaccine at the pharmacy, then payment must be made at the time of the administration of the vaccine. I acknowledge that my vaccination record may be shared with federal or state or city agencies for registry reporting. I acknowledge that the pharmacist recommends that vaccinated patients should remain in the waiting area, for 15 minutes, after the administration of the immunization. I acknowledge receipt of Care Trust’s Notice of Privacy Practices for Protected Health Information. I have read, or have had read to me the Vaccination Information Sheet (VIS) regarding the vaccine(s). I have had the opportunity to ask questions that were answered to my satisfaction and understand the benefits and risks of the vaccine(s). I consent to, or give consent for, the administration of the vaccine(s). I fully release and discharge Care Trust Pharmacy, its affiliates, officers, directors, and employees from any liability for illness, injury, loss, or damage which may result there from the vaccination.

Patient Signature or Legal Guardian Signature (needed for anyone under 18 years old) *

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If legal guardian type in name here:

First NameLast Name