• COVID Vaccine Consent Form

    COVID Vaccine Consent Form

  • VACCINES WILL NOW BE ADMINISTERED IN THE PHARMACY

    If you still prefer to receive your vaccine in your vehicle, please call the pharmacy once you have arrived and we will come out to you. Thank you!

  • IMPORTANT UPDATES

    • NEW BI-VALENT COVID-19 BOOSTER AVAILABLE - AT LEAST 2 MONTHS FROM PREVIOUS BOOST - INTERCHANGEABLE
    • COVID VACCINES GIVEN ON TUESDAYS AND THURSDAY TO REDUCE WASTE 
      • BIVALENT MODERNA 
        • 6 YEARS +
        • PEDIATRIC: 6 months to 5 years 
      • BIVALENT PFIZER (**currently unavailable**)
        • 12 YEARS +
    • Flu shots are available 
    • MORE INFORMATION: HERE - UPDATED 12/30/22
  • Section 1: Vaccine Recipient Information

  •  - -
    Pick a Date
  • HELP YOUR CHILD GET OVER SHOT ANXIETY

     

    Child Shot Anxiety

     

    Taking Fear and Pain Out of Needles

  • PLEASE BRING YOUR COVID-19 VACCINATION CARD TO YOUR APPOINTMENT.

    THANK YOU!

  • Section 2: COVID-19 Pre Vaccination Assessment:

    The following questions will help us determine if there is any reason you should not get the COVID-19 vaccine today. If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions may be asked. If a question is not clear, please ask your healthcare provider to explain.

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  • Prescription insurance (may skip if previous shot at pharmacy):
    ID #:     RX BIN:       
    RX GROUP (GRP):    RX PCN:         

  • MEDICARE PATIENTS:
    If medicare, please provide ID number (Red, White, Blue card):

  • Section 3: Consent

    I have read or have had explained to me the information provided in the Emergency Use Authorization for pfizer (HERE), moderna (HERE), pediatric moderna (HERE) or for Novavax (HERE). I have had a chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of COVID-19 vaccine and ask that the vaccine be administered to me or the person named above for whom I am authorized to make this request.

  • Clear
  • Should be Empty: