COVID-19 Vaccine Registration Form
Note: All Information is HIPAA Secured and only available to Scott County Pharmacy
Who is filling out this form?
Business - Plateau Electric
Business - Takahata
If Other, Please Specify
Which COVID19 Vaccine Are You Looking For?
Moderna - (mRNA, Multi-Shot Series)
Pfizer - (mRNA, Multi-Shot Series)
Janssen (Johnson & Johnson) - Viral Vector
Which Shot in the Series are you looking for?
Second Shot in Series
Third Shot in Series/Booster Shot
Vaccine Recipient's Name
Date of Birth
Gender on Birth Certificate
Vaccine Recipient's Physical Address
Street Address Line 2
State / Province
Postal / Zip Code
Vaccine Recipient's Phone Number
Emergency Contact Name
Emergency Contact Phone Number
Mother's Maiden Name
Hispanic or Latino
Not Hispanic or Latino
Is this your First, Second, or Third Vaccine?
Vaccine Manufacturer of your last dose
Date of Last Dose
Where did you receive your last vaccine?
Scott County Pharmacy
Mt. People's Health Clinic
Big South Fork Medical Center
Scott County Health Department
If Other, Please Specify
Which arm do you prefer to receive the COVID-19 Vaccine in?
PATIENT QUESTIONS - Pre-Screen Questions
1. Are you feeling sick today?
2. Have you ever received a dose of COVID-19 Vaccine before?
3. Have you ever had an allergic reaction to:
* A component to the COVID-19 Vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures.
* Previous Dose of COVID-19 Vaccine?
* Any other vaccine or injectable medication?
* Something other that a component of COVID-19 vaccine, polysorbate, or any other vaccine or injectable medication? (This would include food, pet, environmental, or oral medication allergies)
4. Have you received any vaccine in the last 14 days?
5. Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19?
6. Have you ever received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? [Note: monoclonal antibodies does not include antibiotics that would be prescribed to you and filled at a pharmacy.]
7. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressant drugs or therapies?
8. Do you have a bleeding disorder or are you taking a blood thinner?
9. Are you pregnant or breastfeeding?
Insured or Uninsured
If INSURED, check the box attesting to bringing in your prescription and medical insurance cards for your vaccine appointment. By selecting this, you are also authorizing the pharmacy to bill your insurance on your behalf for the immunization - understanding you will not incur any costs.
If UNINSURED, you must check this box to attest that the following information is true and accurate: I do not have any insurance, including but not limited to, Medicare, Medicaid, or any other private or government-funded benefit plan
What type of insurance do you have?
Commercial Third Party
RxBIN: (ex 017010)
RxPCN: (ex 0125COMM)
RxGroup: (ex. 336391)
01 - Cardholder
02 - Spouse
03 - Child
04 - Other
Cardholder ID: (Found on the TennCare Pharmacy Card)
Medicare Identification Number (MBI) on Red, White and Blue Card
If Uninsured: Obtain one of the following:
Social Security Number
State ID Number
Driver's License Number
State ID State of Issue
Driver's License State of Issue
Please Attest that the Vaccine Recipient Do Not have Insurance
I Attest that I Do Not Have Insurance
Informed Consent to Receive COVID-19 Vaccine
Please Check Each Box
I understand the benefits and risk of the COVID-19 Vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet for the vaccine that I receive (a copy of which will be provided after clicking submit). I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or the person named above, a minor for whom I represent that I am authorized to sign this Consent Form.
I understand at this time, the COVID-19 Vaccine requires 2 doses given 21-28 days apart depending on the manufacturer (with the exception of Johnson & Johnson - JANNSEN). If this is my second dose, I will bring my vaccine card with me to be completed.
I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reaction occur.
I understand that I will be receiving the vaccination at no cost to me.
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform