COVID-19 Vaccine Registration Form
Note: All Information is HIPAA Secured and only available to Scott County Pharmacy
Who is filling out this form?
Please Select
Myself
Spouse
Caregiver
Business - Plateau Electric
Business - Takahata
Other
If Other, Please Specify
Back
Next
Which COVID19 Vaccine Are You Looking For?
Please Select
Moderna - (mRNA, Multi-Shot Series)
Pfizer - (mRNA, Multi-Shot Series)
Janssen (Johnson & Johnson) - Viral Vector
Which Shot in the Series are you looking for?
Please Select
Initial Vaccine
Second Shot in Series
Third Shot in Series/Booster Shot
Back
Next
Vaccine Recipient's Name
First Name
Middle Name
Last Name
Date of Birth
/
Month
/
Day
Year
Date
Gender on Birth Certificate
Please Select
Male
Female
Vaccine Recipient's Physical Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Vaccine Recipient's Phone Number
Email
example@example.com
Emergency Contact Name
First Name
Last Name
Relationship
Emergency Contact Phone Number
Mother's Maiden Name
Race
Please Select
White
African American
Hispanic
Asian
American Indian
Pacific Islander
Other
Ethnicity
Please Select
Hispanic or Latino
Not Hispanic or Latino
Unknown
Is this your First, Second, or Third Vaccine?
First
Second
Third (Booster)
Vaccine Manufacturer of your last dose
Please Select
Pfizer
Moderna
Janssen J&J
Date of Last Dose
/
Month
/
Day
Year
Date
Where did you receive your last vaccine?
Please Select
Scott County Pharmacy
Plateau Drugs
Danny's Drugs
Mark's Pharmacy
Roark's Pharmacy
Mt. People's Health Clinic
Big South Fork Medical Center
Scott County Health Department
Other
If Other, Please Specify
Which arm do you prefer to receive the COVID-19 Vaccine in?
Right
Left
Appointment
Back
Next
PATIENT QUESTIONS - Pre-Screen Questions
No
Yes
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.
* Polysorbate
* 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?
Back
Next
Insured or Uninsured
Check One
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?
Medicare
Medicaid/(TennCare)
Commercial Third Party
Uninsured
Cardholder ID:
RxBIN: (ex 017010)
RxPCN: (ex 0125COMM)
RxGroup: (ex. 336391)
Relationship:
Please Select
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
SSN
State ID
State ID State of Issue
Driver's License
Driver's License State of Issue
Please Attest that the Vaccine Recipient Do Not have Insurance
Please Select
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.
Preview PDF
Submit
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform