COVID VACCINE MODERNA/PFIZER

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

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 / Fourth dose

What vaccine would you like to receive? *

Pfizer (12 years & older, 2 shots total, dosed 21 days apart AND eligible booster at 5 months AND additional eligible boost 4 months later for 50+) Moderna (18 years & older, 2 shots total, dosed 28 days apart AND eligible half-dose booster at 6 months AND additional eligible boost 4 months later for 50+) Pediatric Pfizer (5-11 year old, 2 shots total, dosed 21 days apart AND eligible booster at 5 months)

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

If fourth dose, when did you receive the 3nd dose?

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.

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?
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 (TUESDAY AND THURSDAY) *

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):
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