Vaccine Consent Form Staten Island
In order to receive the vaccine, you must be in the most appropriate phase of the vaccine rollout. Visit this link (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations.html) for more information at the federal level. States may have a different approach.
Which vaccine(s) would you like to receive today (you can receive both)?
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Flu Vaccine (2 years and older only) FREE with most insurances; cash / not covered price $35
Flu Vaccine High Dose (65+) FREE with most insurances; cash / not covered price $75
Pfizer Bivalent Booster
Moderna Bivlaent Booster
Shingles Shot (If COPAY we will email you a link with invoice)
Select an appointment date/time: November 9th
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Vaccine Recipient Name
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First Name
Middle Name
Last Name
Vaccine Recipient HOME Address
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Street Address
Apt #
City
State Initials
Zip Code
Date of Birth
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/
Month
/
Day
Year
Gender at birth
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Please Select
Male
Female
Race
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Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Ethnicity
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Please Select
Hispanic or Latino
Not Hispanic or Latino
Unknown
Vaccine Recipient Phone Number
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Primary Care Provider Name
Emergency Contact Name
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Relationship to Emergency Contact
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Please Select
Brother
Sister
Sibling
Mother
Parent
Father
Guardian
Spouse
Grandparent
Child
Foster child
Stepchild
Care Giver
Other
Phone Number of Emergency Contact
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Email
example@example.com
Vaccine Screening Questions
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Yes
No
1. Are you feeling sick today?
2. Have you ever received a dose of COVID-19 Vaccine?
3a. Have you ever had an allergic reaction to a
component of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures?
3b. Have you ever had an allergic reaction to eggs or diary products?
3c. Have you ever had Gullian-Barre Syndrome?
4. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?
5. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a component of COVID-19 vaccine, polysorbate, or any vaccine or injectable medication?
This would include food, pet, environmental, or oral medication allergies.
6. Have you received any vaccine in the last 14 days?
7. Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19?
8. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?
[note: monoclonal antibodies does not include antibiotics that you would be prescribed and filled at a pharmacy]
9. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
10. Do you have a bleeding disorder or are you taking a blood thinner?
11. Are you pregnant or breastfeeding?
Which arm would you like to get the injection on
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Left Arm
Right Arm
Consent (check each box below after reading and prior to signing the form)
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Check each box
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet (the Moderna Fact Sheet is available after clicking submit), a copy of which I was provided with this Consent Form. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent Form.
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 reactions occur.
I understand that I will be receiving the COVID-19 vaccination at no cost to me.
The vaccine is available to anyone no matter if insured or uninsured. Please check only one of the following.
If INSURED, check this 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 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.
Please Upload Insurance Card
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For uninsured patients, please select at least one of the following that you will bring with you to your appointment.
Social Security Number
State identification number and state of issuance
Driver's license number and state of issuance
Please Upload Supporting Uninsured Document
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Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):
Date Signed
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Month
/
Day
Year
Date
Lot Number
Expiration Date:
Pharmacy Name
Pharmacy NPI
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Submit Consent Form (required)
Should be Empty: