MVP COVID-19 Vaccine Consent Form

Mt. Vernon Pharmacy

900 Cathedral St.; Baltimore, MD 21201

Voice: 410.539.8030; Text: 410.862-4656; Fax: 410-539-8115 www.mtvernonpharmacy.com

Please READ ALL of the information below. 1) We are providing (as available from our Federal Partners) Janssen/Johnson & Johnson (1-Dose), Moderna, and Pfizer (2-Dose or 3rd Dose booster if qualified) COVID-19 Vaccines at this time for those 18 years and older. No Appointment needed and vaccines will be given on a walk-in basis Monday thru Friday from 9:00 am to 4:00 pm, and Saturdays from 9:30 am to 1:00 PM. 2) Please submit this form. If you have the ability to print the form prior to submitting it, please do so and bring your copy of the form with you to the pharmacy. If you do not have the ability to print the form, then submit and when you arrive at the pharmacy, just let the pharmacy team member know that you submitted the form electronically. We will be able to retrieve it for you. 3) If printing, you must download PRIOR to clicking the submit button as you will not be able to retrieve the form after you submit. 4) If you have prescription insurance coverage or Medicare (Red, White, Blue card), please upload those crads and bring those cards with you to the appointment. If you do not have prescription insurance coverage, please bring your state identification with you and have your social security number available. If you do not have either of these items, please be assured that you WILL be able to receive the vaccine. 5) Prior to arriving for your vaccine, please READ the following EUA (Emergency Use Authorization) for Recipients/Caregivers for the vaccine that you wish to receive upon arrival: Janssen/J&J EUA for Recipients , Moderna EUA for Recipients, or Pfizer EUA for Recipients 6) If you are using this form to obtain a 3rd dose booster, please read carefully. We are only providing Pfizer & Moderna boosters at this time. 6) Any questions, please contact Steve Wienner, Pharmacist

Name *

First Name Last Name

Patient Email Address *

Date of Birth *

Date

Gender Associated With Your Insurance Coverage:

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Please upload a copy of driver's license or MVA ID card if available.

Social Security Number: We use this to retrieve your insurance info.

Cell Phone Number *

Please enter a valid phone number.

Primary Care Physician (if applicable)

Primary Care Phone (if known)

Please enter a valid phone number.

Primary Care Fax (if known)

Please enter a valid phone number.

Race (required for State Vaccination Registry) *

Ethnicity (required for State Vaccination Registry) *

Mother's Maiden Name (required for State Vaccination Registry) *

Have you Screening Questions - if you answer "yes" please include details in the comment section *

	YES	NO	Unsure
Do you feel sick today?
Have you received a dose of COVID-19 vaccine before today?
Have you ever had a serious allergic reaction to something? (ie. that you needed an "Epi-Pen" or had to go to the hospital) *You will be required to stay for 30 min after your vaccine
Have you received another (non-COVID) vaccine in the last 14 days? If Yes, please put name in comments
Have you ever had a severe allergic reaction after receiving another vaccine or injectable medication? If yes, please enter name in comments and you will be required to stay for 30 min after your vaccine)
Have you had a positive test for COVID-19 in the last 90 days?
Have you received monoclonal antibodies or convalescent plasma as treatment for COVID-19 in the last 90 days?
Do you have a weakened immune system caused by a medical condition (HIV, cancer, etc) or immunosuppressive drug therapy?
Are you pregnant (or think you may become pregnant in the next month) or breastfeeding?
Is this a booster dose, and if so, do you qualify based on CDC booster requirements? If not sure, ask pharmacist.

If you previously received a Covid-19 vaccination, which manufacturer did you receive?

Moderna Pfizer Janssen/ J&J

Comments to any Yes Answers

*Persons who have had a severe reaction to a vaccine or currently have an acute febrile illness should not receive a vaccine. I consent to the staff to adminster the vaccination(s) mentioned below. I understand that this vaccine has been authorized by the FDA under an Emergency Use Authorization and I have reviewed the fact sheet listed above, concerning the specific manufacturer of the vaccine I am receiving. I understand the benefits and risks of receiving this vaccine and choose to assume this risk. I fully release and discharge the pharmacist and the pharmacy, its affiliations and their officers and employees from any illness, injury, loss, or damage that may result there from. I acknowledge that I have received a copy of the pharmacy's privacy policies according to HIPAA. I assign payment of authorized insurance benefits due to me to be paid to the pharmacy. I consent the release of medical information when necessary for billing, reimbursement, and medical protocol. I also allow for the pharmacy to report any vaccinations received to the appropriate state vaccine registry. I am aware that an immunization certified student pharmacist might be administering this vaccine. I agree to wait near the vaccination area for a minimum of 15 minutes or as otherwise instructed by the pharmacist so that I may receive treatment if I begin to feel unwell.

In which arm would you prefer to receive the injection?

Left Right

Which Covid vaccination do you want to receive today?

Janssen/ JNJ Moderna Pfizer

Medicare Part B ID Number

Medicare Pt B Effective Date

Date

Upload front of Insurance Card (If so, NO NEED TO ANSWER INSURANCE QUESTIONS.)

Upload back of Insurance Card (If so, no need to answer insurance questions.

Private Prescription Insurance ID Number

Prescription Insurance Help Desk Number (on Card)

Please enter a valid phone number.

Bin # (on Rx card)

RX Group (on Rx Card)

Rx PCN Number (on Rx Card)

Signature *

Clear

Date Signed *

Date

We will text you once we have uploaded your demographic information into our records. If you go to the pharmacy prior to getting a confirmation text, you will most likely have to fill this same form out in the pharmacy, again. Thank you.