COVID VACCINE MODERNA/PFIZER

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

Name: *

Date of Birth:*

AGE:*

Phone Number:*

Email Address:

Primary Healthcare Provider:

Address:*

Street Address (NO PO BOXES)

Street Address Line 2

CityState

Zip Code

Gender*

M = Male, F = Female, T = Transgender, U = Unknown

Ethnicity: *

Race: *

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

First DoseSecond DoseBivalent Booster

What vaccine would you like to receive?*

Moderna (12 years & older, 2 shots total, dosed 28 days apart)Pediatric Moderna (6 months to less than 12 years, 2 shots total, dosed 28 days apart)Novavax (12 years and older, 2 shots total, dosed 3-8 weeks apart)

What age range does the child fall into?

6 months to 5 years old6 years to 11 years old

What vaccine would you like to receive (Moderna for age 6 month+, Pfizer for 12+ (currently unavailable), both must be 2 months after most recent COVID vaccine)? (Pfizer and Moderna are interchangable**)*

Moderna Bivalent BoosterModerna Bivalent Booster + Flu Shot

What vaccine did you receive?*

PfizerModernaJohnson and JohnsonNovavax

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 including eggs? 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?
9. In the last 60 days, have you had a COVID Vaccine?

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 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.

Signature:*

Clear

Have you received any previous COVID-19 vaccines at Scott Pharmacy?

YesNo

COVID Vaccine Consent Form