COVID VACCINE MODERNA/PFIZER

11/19/21 IMPORTANT UPDATE

-People 18 years and older: ALL adults are eligible for booster shots

Moderna / Pfizer booster at least 6 months after second shot

Johnson and Johnson booster at least 2 months after first shot

-People 18 years and older: Mix-and-Match may be considered for booster dose ONLY.

-Pfizer Pediatric dose (5-11 year-olds): ***Two-dose series now approved***

Section 1: Vaccine Recipient Information

Name: *

Date of Birth: *

Phone Number: *

Email Address:

Primary Healthcare Provider:

Address: *

Street Address (NO PO BOXES)

Street Address Line 2

City State

Zip Code

Gender *

Ethnicity: *

Race: *

What dose of the COVID-19 Vaccine will this be? *

First Dose Second Dose Third dose / Booster

What vaccine would you like to receive? *

Pfizer (12 years & older, 2 shots total, dosed 21 days apart AND eligible booster at 6 months) Moderna (18 years & older, 2 shots total, dosed 28 days apart AND eligible half-dose booster at 6 months) Johnson & Johnson (1 shot AND eligible booster at 2 months) Pediatric Pfizer (5-11 year old, 2 shots total, dosed 21 days apart)

What vaccine did you receive? *

Pfizer Moderna Johnson and Johnson

When did you receive the 1st dose? *

Date

When did you receive the 2nd dose? *

Date

For third booster, please select one of the following options. *

Immunocompromised General population

For immunocompromised, please explain. *

Please select what CDC recommendation you fit into for the booster vaccine: *

People 65 years and older OR residents in long-term care settings People aged 18–64 years with underlying medical conditions (cancer, chronic kidney disease, chronic lung disease including COPD/asthma, dementia, diabetes, down syndrome, heart conditions, HIV infection, immunocompromised, BMI > 25 kg/m2, pregnant, smoker, cerebrovascular disease). People aged 18-64 years who are at increased risk for COVID-19 exposure and transmission because of occupational (first responders, educational staff, food and agriculture workers, manufacturing workers, correctional workers, U.S. Postal workers, public transit, and grocery store workers) People aged 18-64 years. CDC states aged 50+ should get booster shots, and 18-49 years may get a booster vaccine.

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.

Please answer the following: *

	Yes	No	Don't know
1. Are you feeling sick today?
2. Have you ever had a severe allergic reaction (e.g. anaphylaxis) to something? For example, a reaction for which you were treated with epinephrine or EpiPen, or for which you had to go to the hospital?
3. In the last 90 days, have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as a treatment for COVID-19?
4. Have you received another vaccine in the last 14 days?
5. In the last 14 days, have you tested positive for COVID-19?
6. Do you have a weakened immune system caused by something, such as HIV infection or cancer, or do you take immunosuppressive drugs or therapies?
7. Do you have a bleeding disorder or are you taking a blood thinner?
8. Are you pregnant or breastfeeding?

Please pick an appointment slot for your vaccination. **PLEASE NOTE: WEEK OF DECEMBER 7TH, THE PHARMACY IS HAVING A NEW SOFTWARE INSTALLED AND WILL BE LIMITING COVID VACCINES.** *

Prescription insurance (type "1" if pharmacy already has):
ID #: * RX BIN: *
RX GROUP (GRP): * RX PCN: *

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

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.

Signature: *

Clear

COVID Vaccine Consent Form