• COVID Vaccine Consent Form

  • IMPORTANT UPDATES

    • AGES 5 - 11 ARE ELIGIBLE TO RECEIVE A BOOSTER (3RD VACCINE)
      • MUST BE 5 MONTHS FROM PRIMARY SERIES
    • CDC RECOMMENDS FOURTH PFIZER AND MODERNA VACCINE FOR PEOPLE 50 AND OLDER
      • FOURTH DOSES MUST BE AT LEAST 4 MONTHS FROM PREVIOUS BOOST
    • MORE INFORMATION: HERE  - UPDATED 5/20/22
  • WEATHER CONDITIONS

    -If weather conditions are poor (raining / snowing / negative temperatures) please plan on coming inside for the vaccination with your vaccine card / insurance card. 

    -If unable to make appointment please call to reschedule or cancel. 

    THANK YOU!!!

  • Section 1: Vaccine Recipient Information

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  • 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 pediatric pfizer (HERE), pfizer (HERE) or for moderna (HERE) or for Johnson and Johnson (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.

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