Vaccine Appointment & Consent Form

Vaccine Appointment*
-Available Vaccines - To submit a form for the Covid-19 MODERNA or CHILDREN'S 5-11 vaccine please visit our website for correct form and available dates*

Shingles Vaccine -Shingrix- Must be 50 years of age or olderTdap - Tetanus, Diphtheria & Pertussis - Must be 14 years of age or olderPneumonia Vaccine - must be 65 years of age or olderFlu Vaccine - Quad - must be 7 years of age or older
Vaccine Appointment & Consent Form NO COVID "BOOSTERS" at this time

The FDA/CDC has amended their emergency use authorizations (8/31/22) of the Moderna and Pfizer vaccine "boosters". They are in the process of distributing a new "booster" vaccine. We will make these available as soon as we receive them. Thank you for your support, stay safe and healthy.
Contact Information

Please complete for the person receiving a vaccine
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Vaccine Form

*Required for state immunization reporting purposes*
If you are receiving a multi-dose vaccine, are you scheduling your 1st, 2nd, 3rd or 4th dose?*
If you are unsure when to schedule your follow-up vaccine please see below for the CDC recommendations.
2nd dose recommendations

Pfizer - 3-5 weeks following the 1st dose

Moderna - 4-6 weeks following the 1st dose

3rd dose recommendations - Only CDC approved for Mod-Sev immunocompromised

CDC recommends an additional dose of the Pfizer or Moderna vaccine be administered at least 4 weeks after the 2nd dose for only those who are moderately to severely immunocompromised.

Who needs a 3rd Covid-19 Vaccine?

Currently, CDC is recommending that moderately to severely immunocompromised people receive an additional dose. This includes people who have: Been receiving active cancer treatment for tumors or cancers of the blood, received an organ transplant and are taking medicine to suppress the immune system, received a stem cell transplant within the last 2 years or are taking medicine to suppress the immune system, advanced or untreated HIV infection, moderate or severe primary immunodeficience (such as DiGeorge syndrom, Wiskott-Aldrick syndrom) or active treatment with high-dose corticosteroids or other drugs that by suprress you immune system.
Date of birth of person getting vaccinated*

MonthDayYear
Date
Sex*
Social Security Number *Required for C19 Vaccines*
Required for Covid-19 Vaccines State Registry
Mother's Maiden Name *Required for C19 Vaccines*
County of Residence *
Race*
Ethnicity*
By my signature below, I GRANT consent for registration. I wish to INCLUDE my information in the Texas immunization registry State-run immunization registry. (Required)*

Yes
Medical History

Screening*

	Yes	No	Don't know
Are you feeling sick or experiencing a moderate to high fever today?
Do you have allergies to latex, food, medications, or vaccine components? (such as eggs, thimerosal, gelatin, neomycin, phenol, or bovine protein)?
Did you ever experience any serious reaction after getting a vaccine?
In the past year, did you receive a transfusion of blood or blood products, or get injected immune (gamma) globulin or any antiviral drug?
Did you have any brain or other nervous system problems?
Have you been vaccinated in the last 4 weeks?
Are your pregnant or planning to get pregnant or your partner is planning to get pregnant?

Do you have any of the followings? (select all that apply)*

Lung diseaseHeart diseaseAsthmaKidney DiseaseDiabetesAnemiaBlood disorderNone
Do you have immunocompromised condition? (select all that apply)*

CancerLeukemiaLymphomaHIV/AIDSTransplantAspleniaCSF leakCochlear implantNone
Have you ever tested positive for COVID-19?

YesNo
Test Date

MonthDayYear
Date
In the last 14 days, have you contacted with a person who was confirmed to have COVID-19?

YesNoNot sure
In the last 14 days, have you travelled internationally?

YesNo
Do you have any of the followings?*

CoughColdFeverShortness of breathSore throatLoss of smell/tasteAbdominal pain/diarrheaAbnormal bruising or bleeding/eye rednessNone
Emergency Contact Information
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relation
Insurance Information
Do you currently have medical/prescription insurance*

YesNo
If possible, please upload a picture of your pharmacy insurance card or Medicare card.

Cancelof
Medicare Health Insurance ID (see Red, White and Blue Card) if applicable
Prescription Insurance Information: Member ID
Prescription Insurance Information: Rx Bin
Prescription Insurance Information: Rx Group
Prescription Insurance Information: Rx PCN
By signing this form,

I hereby accept that I have read and understood the acknowledgment letter provided below.

I declare that the information I have provided above is correct.

I am giving my full consent to the vaccine chosen of my own free will.

I certify that I am: (a) the and at least 18 years of age or (b) the parent or legal guardian of the patient. Further, I hereby give my consent to the healthcare provider of Red Door Pharmacy and Gifts, to administer the vaccine(s) I have requested. I understand the risks and benefits associated with the vaccine(s) and have received, read and/or had explained to me the vaccine information statements on the vaccine(s) I have elected to receive. I also acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction. On behalf of myself, my heirs and personal representative, I hereby release and hold harmless the applicable Provider, its staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors and employees 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 the vaccine(s) listed. I acknowledge that, the purposes/benefits of my state's immunization registry "state registry" and the provider may disclose my immunization information to the State Registry. I acknowledge that, depending upon my state's law, I may prevent the disclosure of my immunization information by the applicable provider to the state registry by using the opt-out form. The provider will, if my state permits, provide me with an opt-out form. I understand that, depending on my state's law, I may need to specifically consent, and to the extent required by my state's law, by signing below, I hereby do consent to the provider reporting my immuniztion information to the State Registry. I understand that even if I do not consent or if I withdraw my consent, my state's laws may permit certain disclosures of my immunization information as required or permitted by law. I voluntarily authorize and direct my healthcare provider at Red Door Pharmacy and Gifts to use or disclose my health information during the term of this authorization to the physician responsible for this protocol of specific health information of people vaccinated at Red Door Pharmacy and Gifts, my primary care physician, my insurance and/or state or federal registries, where required for the purpose of treatment, payment or other healthcare operations. I further agree to be fully financially responsible for any cost sharing amounts, including copays, coinsurace, and deductibles, for the requested items and services as well as for any requested items and services not covered by my insurace benefits. I understand that any payment for which I am financially responsible is due at the time of service.

Please be aware that the vaccine is not completely effective like all other medicines. It can take a few weeks for your body to build up protection from the vaccine. There is always a chance to get infected by a virus even with the vaccine; however, the vaccine lessens the severity of any infection.

Vaccines have some side effects as medicines, but not everyone gets them.

The most likely side effects that you may experience from a vaccine
- Fever
- Pain at the injection site
- Redness and hardness of the skin at the injection site
- Headache
- Muscle aches or pain
- Joint aches or pain
- Fatigue (tiredness)
- Nausea/vomiting
- Chills
- Underarm gland swelling on the side of study vaccination
If you think you are experiencing any side effects, please remain calm and see your doctor immediately.

If you are currently pregnant or planning to get pregnant or your partner is planning to get pregnant; please see your doctor before getting vaccinated.
Signature*

Clear
Date*

MonthDayYear
Date
If you would like to reserve an appointment for the Flu Vaccine for up to 4 people in your household please list the names and birthdays of each individual below. Covid-19 Vaccines require each individual to complete the form above independently.
First Name   Last Name   Date of Birth
First Name   Last Name   Date of Birth
First Name   Last Name   Date of Birth
Should be Empty:

Vaccine Appointment & Consent Form NO COVID "BOOSTERS" at this time

Contact Information

Vaccine Form

2nd dose recommendations

3rd dose recommendations - Only CDC approved for Mod-Sev immunocompromised

Who needs a 3rd Covid-19 Vaccine?

Medical History

Emergency Contact Information

Insurance Information