COVID-19 Vaccine Appointment Form

COVID-19 Vaccine Patient Intake and Consent Form

Please complete all fields to the best of your knowledge.
Vaccine Information
How did you hear about Aviva Pharmacy? (If through your doctor, please list your doctors name)
I am registering for: *

Moderna Vaccine Pfizer Vaccine Johnson & Johnson Vaccine (Janssen)
I am registering for my: *

1st Dose 2nd Dose (Moderna & Pfizer ONLY) 3rd Dose (Booster - Moderna & Pfizer ONLY)
Do you have health insurance? *

Yes No

Personal Information
The information you provide here is intended for internal use only
Name *

First Name Last Name
Date of Birth *

Month Day Year
Age *
Gender *

Male Female Other
PLEASE NOTE: We will E-Mail and/or TEXT you information regarding your vaccine and/or appointment

SO MAKE SURE ALL INFO IS ACCURATE
Email *
example@example.com
Mobile Phone Number *
PLEASE NOTE: We will call and text you regarding your appointments.
Consent to Receive Text Messages from Aviva Pharmacy

By signing below, I authorize Aviva Pharmacy through its vendor SlickText to contact me by SMS text message to serve me better. Aviva Pharmacy will send me text messages through the Aviva Pharmacy member outreach program to help me or my child stay healthy, including: 1) important information regarding COVID-19 2) links and resources regarding your COVID-19 vaccination plan 3) pharmacy-related reminders and promotional messages 4) information to help manage illnesses. I understand that message/data rates may apply to messages sent through Aviva Pharmacy to my cell phone and that I may receive up to 10 texts per month. I know that I am under no obligation to authorize Aviva Pharmacy to send me text messages as part of this program. I may opt-out of receiving these communications from Aviva Pharmacy at any time by calling Aviva Pharmacy @ (562) 888-1277 or by texting 'STOP' to (844) 283-8071.
Address *

Street Address

Street Address Line 2

City State

Zip Code
Emergency Contact Information
Emergency Contact Name *

First Name Last Name
Relation to Patient *
Emergency Contact Phone Number *
Please enter a valid phone number.
Insurance Information
Note: Make sure you also bring your Medicare ID to your vaccination appointment.
MediCare Information

(If 65+)
Upload an image of your MediCare card: *

Cancel of
Insurance Card

(Please upload an image of both sides of your insurance card)
Upload an image of the FRONT of your insurance card: *

Cancel of
Upload an image of the BACK of your insurance card: *

Cancel of

Schedule Appointment

Please show up to Aviva Pharmacy at your scheduled time. Arriving late may result in rescheduling your appointment.
First Dose Appointment *

About The Vaccine

Please read and understand the information below and sign and date the form when finished.
The COVID-19 vaccine will reduce the risk of being infected by the new type of Coronavirus disease, known as COVID-19.

Please be aware that the vaccine is not completely effective like all other medicines. It can take a few weeks for your body to build up protection from the virus. There is always a chance to get infected by Coronavirus even with the vaccine; however, the vaccine lessens the severity of any infection. Two doses will reduce the chance of being seriously ill and reduce the risk of death due to Coronavirus.

This vaccine does reduce your risk for COVID-19 infection, but you still need to follow the health instructions in your workplace and in public areas, such as wearing a mask and keeping the distance from others.

The vaccine may have some side effects similar to other vaccines, but not everyone gets them.

The most likely side effects that you may experience from the COVID-19 vaccine are:
- Fever
- Pain at the injection site
- Redness and hardness of the skin at the injection site
- Headache
- Muscle aches or pain
- Joint aches or pain
- Fatigue (tiredness)
- Nausea/vomiting
- Chills
- Underarm gland swelling on the side of study vaccination
If you think you are experiencing any side effects, please remain calm and contact your doctor immediately.

If you are currently pregnant, planning to get pregnant, or your partner is planning to get pregnant; please see your doctor before getting vaccinated.

Please note that per the CDC, all vaccine recipients should remain on site for observation for a minimum of 15 minutes. Persons with a history of immediate allergic reaction of any severity to a vaccine or injectable therapy and/or history of anaphylaxis due to any cause should be observed for 30min.

If you have any serious adverse side affects or symptoms as a result of the vaccine please contact 911 and report these to the CDC by visiting www.https://vaers.hhs.gov/
Acknowledgement
By signing below, I consent to the administration of the vaccine(s) by a pharmacist or a supervised student pharmacist or technician, where permitted by law or state/federal guidance, employed by Aviva Pharmacy and to be contacted at the number provided above regarding other immunizations for which I am due or eligible to receive. I also release Aviva Pharmacy and its subsidiaries, affiliates, officers, directors, employees, and agents from all liability, including acts of omission or commission, resulting or arising from my receipt of this vaccination. I understand that: 1) I have voluntarily chosen to receive the vaccination and understand that I am obligated to pay for all products and services received, if applicable. 2) I may be responsible for payment after the date of service if the product or service is billed to my medical benefit. 3) I am of legal age and authorized to execute this consent form or I am the parent/guardian of the minor patient. 4) I will immediately alert the pharmacist of any medical conditions which may adversely affect my personal health or effectiveness of the vaccine. 5) I have been counseled about potential side effects after vaccination, when they may occur, and when and where I should seek treatment. I am responsible for following up with my physician at my expense if I experience any side effects. 6) I should remain in the area for 15 minutes after the vaccination for observation. 7) I understand I may request the Vaccine Information Statement(s) (“VIS”) or Emergency Use Authorization (“EUA”) to be provided to me for the vaccine(s) to be administered. I have had the opportunity to ask questions, and all my questions have been answered to my satisfaction. I understand the benefits and risks of the vaccine(s). 8) I understand I can request a copy of the company’s Notice of Privacy Practices in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 9) This vaccination, including any vaccination granted additional privacy protections under state or federal law, is subject to reporting by my pharmacy or its business associate to an immunization registry, which may share my immunization data with others, and to my primary care physician, the authorizing physician, or the local Department of Health, if applicable, and I authorize these disclosures. 10) I understand that if I have any serious side affects or symptoms from the vaccine I need to contact a medical professional and in the event of an emergency we recommend to contact emergence personel or contact 911.

Consent to Receive Text Messages from Aviva Pharmacy

By signing below, I authorize Aviva Pharmacy through its vendor SlickText to contact me by SMS text message to serve me better. Aviva Pharmacy will send me text messages through the Aviva Pharmacy member outreach program to help me or my child stay healthy, including: 1) important information regarding COVID-19 2) links and resources regarding your COVID-19 vaccination plan 3) pharmacy-related reminders and promotional messages 4) information to help manage illnesses. I understand that message/data rates may apply to messages sent through Aviva Pharmacy to my cell phone and that I may receive up to 10 texts per month. I know that I am under no obligation to authorize Aviva Pharmacy to send me text messages as part of this program. I may opt-out of receiving these communications from Aviva Pharmacy at any time by calling Aviva Pharmacy @ (562) 888-1277 or by texting 'STOP' to (844) 283-8071.
By checking this box I agree and attest that I am eligible for the COVID-19 Vaccine in accordance to the CDC guidelines. To see the most current guidelines published by the CDC click the link below. *
For more information about the vaccine or current eligibility requirements, please click HERE.
Date *

Month Day Year
Date
Signature *

Clear

Sorry, you are not eligible for the COVID-19 Vaccine at this time.

Please return to this form when you are eligible (see reasons below).
You are NOT eligible for the vaccine at this time due to the following reasons:
- You are currently sick or showing signs of illness
- In the past 14 days, you have tested positive for COVID-19 or are being treated/monitored for COVID-19
- In the past 14 days you have experienced any of these symptoms: cough, cold, fever, shortness of breath, sore throat, loss of smell or taste, abdominal pain/diarrhea
- You have an allergy or reaction to vaccines or any of their ingredients
Learn more about California's COVID-19 Vaccine Distribution Plan and when you may be eligible to receive the vaccine:

https://covid19.ca.gov/vaccines/#When-can-I-get-vaccinated
Should be Empty:

	Yes	No
Are you sick today?
For women: Are you pregnant or are you considering becoming pregnant in the next month?
Have you received the TDap vaccine within the last two weeks?
Do you take any anticoagulation medication?
Do you have a medical condition or take medication(s) that may weaken your immune system?
Do you have an immunocompromised condition?
Do you have a seizure disorder or a brain disorder?
In the last 14 days, have you contacted with a person who was confirmed to have COVID-19?
Have you ever tested positive for COVID-19?
In the past 14 days, have you tested positive for COVID-19 or are currently being treated for COVID-19?
In the past 14 days, have you travelled internationally?
Do you currently or have you in the past 14 days experienced any of the following symptoms? (cough, cold, fever, shortness of breath, sore throat, loss of smell or taste, abdominal pain/diarrhea)

COVID-19 Vaccine Patient Intake and Consent Form

Vaccine Information

Medical History

Personal Information

Emergency Contact Information

Insurance Information

MediCare Information

Insurance Card

Schedule Appointment

About The Vaccine

Acknowledgement

Sorry, you are not eligible for the COVID-19 Vaccine at this time.