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 Covid Vaccine Signup 
 Covid Vaccine Signup 
Appointments available are currently for vaccinations at Vashon Pharmacy (we are not conducting mass clinics at other venues at this time)  
21Questions
COVID 19 VACCINATION AND BOOSTER FORM
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    MM / DD / YYYY - Leave date populated if this is patients first vaccination.
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    NOTE: Immunocompromised patients should wait minimum 28 days before receiving a booser - all other 3rd dose booster should be given at least 6 months after the 2nd dose.
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    PLEASE NOTE: A parent or Legal Guardian must authorize vaccination of a minor
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    Name of patient being vaccinated
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    Please use the MM-DD-YYYY format
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    Please Select
    • Please Select
    • United States
    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
    • Bhutan
    • Bolivia
    • Bosnia and Herzegovina
    • Botswana
    • Brazil
    • Brunei
    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cambodia
    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curaçao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic
    • Ecuador
    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
    • Estonia
    • Ethiopia
    • Falkland Islands
    • Faroe Islands
    • Fiji
    • Finland
    • France
    • French Polynesia
    • Gabon
    • The Gambia
    • Georgia
    • Germany
    • Ghana
    • Gibraltar
    • Greece
    • Greenland
    • Grenada
    • Guadeloupe
    • Guam
    • Guatemala
    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Honduras
    • Hong Kong
    • Hungary
    • Iceland
    • India
    • Indonesia
    • Iran
    • Iraq
    • Ireland
    • Israel
    • Italy
    • Jamaica
    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kenya
    • Kiribati
    • North Korea
    • South Korea
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
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    This email will be used for confirmation and communication purposes.
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    This number contains Numbers and Letters and is located on your RED, WHITE and Blue paper card
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  • 17
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    Omicron Booster will be either Pfizer or Moderna, which vaccine is given on a particular day will be determined by supply given to Vashon Pharmacy.
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  • 19
    Penicillin, Sulfa, Etc..
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  • 20
    select all that apply
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    If no times appear scroll to next month to find available date AND time
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    IF YOU NEED A MODERNA FIRST OR SECOND DOSE VACCINE PLEASE CALL THE PHARAMACY TO MAKE APPT. ALL OMICRON BI-VALENT BOOSTER APPT SHOULD SELECT 'OMICRON BOOSTER' IN THE "WHAT VACCINE DO YOU WISH TO RECEIVE?" QUESTION
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    These appointments will take place at Vashon Pharmacy
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  • 32
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    IMPORTANT!!!

    Current guidelines require minimum of two months between a patient's last covid vaccine and the new covid booster. Your vaccine eligibility date is:

    {vaccineBooster}

    Please select a vaccination date that is after the date listed above by going back to the appointment calendar and selecting a later date. Failure to select a proper date will result in the automatic cancellation of your appointment. 

    Should this date be incorrect please return to question 2 and correct the date. 

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  • 34

    IMPORTANT!!!!

     

    You have selected an OMICRON BOOSTER for a patient under the age of 12. Current EUA's do not cover Omicron vaccination in patients under the age of 12. If this selection was made in error please return to the question and correct this mistake or return to fill out this form once EUA has been approved in younger populations. 

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  • 35
    We will select the age appropriate flu vaccine based on answers to the above question.
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  • 36

    • I certify that I am: (a) the patient and atleast 18 years of age; (b) the legal guardian of the patient and confirm thatthe patient is at least 18 years of age; or (c) authorized to consent forvaccination for the patient named above. Further, I hereby give my consent to VashonPharmacy or its agents to administer the COVID-19 vaccine. I also acknowledge that if this is being filled our for a booster dose that I have answered each question honestly.

    • I understand that this product has not been approved orlicensed by FDA, but has been authorized for emergency use by FDA, under an EUAto prevent Coronavirus Disease 2019 (COVID-19) for use in individuals 18 years of age and older; and the emergency use of this product is only authorized forthe duration of the declaration that circumstances exist justifying the authorization of emergency use of the medical product under Section 564(b)(1)of the FD&C Act unless the declaration is terminated or authorization revokedsooner.

    • I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccine(s). I understand the risks and benefits associated with the above vaccine and havereceived, read and/or had explained to me the Emergency Use Authorization Fact Sheet on the COVID-19 vaccine I have elected to receive. I also acknowledgethat I have had a chance to ask questions and that such questions were answered to my satisfaction.

    • I acknowledge that I have been advised to remain near thevaccination location for approximately 15 minutes (or more in specific cases)after administration for observation. If I experience a severe reaction, I willcall 9-1-1 or go to the nearest hospital.

    • On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless the Vashon Pharmacy, the WashingtonDepartment of Health (DOH), and their staff, agents, successors, divisions,affiliates, subsidiaries, officers, directors, contractors and employees fromany and all liabilities or claims whether known or unknown arising out of, inconnection with, or in any way related to the administration of the vaccinelisted above.

    • I acknowledge that:(a) I understand the purposes/benefits of Washington’s immunization registry and (b) Vashon Pharmacy will include my personal immunization information in the IIS registry and my personal immunization information will be shared with theCenters for Disease Control (CDC) or other federal agencies.

    • I further authorize Vashon Pharmacy or its agents tosubmit a claim to my insurance provider or Medicare Part B without supplemental coverage payment for me for the above requested items and services. I assign and request payment of authorized benefits be made on my behalf to Vashon Pharmacy or its agents with respect to the above requested items and services.

    • I acknowledge receipt of the Notice of Privacy Rights.

     

    By clicking signing below I accept these terms and conditions.

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    CLICK NEXT IF YOU ARE OVER 18
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    You may click previous to read again if needed
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