Sharpsburg Pharmacy PFIZER COVID-19 Vaccine Consent Form

17316 Shepherdstown Pike
Sharpsburg, MD 21782
p: 301.432.7223 - f: 301.432.4423
www.sharpsburgpharmacy.com

Thank you for your interest in scheduling a Pfizer COVID-19 Vaccine (first dose or booster) at Sharpsburg Pharmacy! Please DO NOT schedule an appointment if you want a different vaccine because other vaccines appointments cannot be scheduled through this form. You must be at least 12 years of age for us to administer the adult Pfizer vaccine or the bivalent booster. If this is your first dose, you will need to return to the pharmacy exactly 21 days after your appointment so that you can receive your second dose. If you cannot return in 21 days for the second dose, DO NOT schedule an appointment until you would be able to do so 21 days later. Because of the dose allocations and storage requirements we simply cannot accomodate requests to reschedule your second dose because of vacations, other appointments, etc.

If all the appointment times below are grayed out, they have been taken. Please keep checking back because we will open more times as vaccine becomes available to us.

We recommend that you make a NOTE of your APPOINTMENT Date and Time and DOWNLOAD/PRINT the PDF form for your records once you hit submit. You may do this on the "Thank You" page that appears after your form is submitted successfully. Please bring this and any insurance cards with you for your appointment. An email confirmation of your appointment will be sent but many email providers send Jotform emails to their spam or junk mail folders. Please check these folders before calling the store to confirm.

Starting 9/2/22

CDC now recommends a single booster dose of a bivalent mRNA COVID-19 vaccine for certain individuals after receipt of a primary series (with any approved or authorized COVID-19 vaccine) or prior monovalent booster dose. Eligible individuals must be ≥ 12 years of age to receive the bivalent Pfizer-BioNTech COVID-19 booster vaccine. The enhanced booster shot should be administered to all persons in this age range, regardless of the number of monovalent booster doses the person previously received, as long as the bivalent booster dose is given at least 2 months (8 weeks) after any previous dose.

In addition to a mRNA COVID-19 booster, immunocompromised people should continue to take precautions such as wearing masks, avoiding crowds, and keeping their physical distance from people they don't live with. Likewise, everyone around immunocompromised people should get vaccinated against COVID-19 to protect their loved ones.

You will be asked to present your vaccine card showing your previous vaccine doses.

If you are unable to select a vaccine appointment time below we are currently full, please check back regularly as appointments open up as other patients cancel. You can call the store late in the day on vaccination days to check for availability of extra doses.

If you need to cancel an appointment please call us so that we can open the spot up for someone else. No shows for appointments can mean that we have to waste a dose that day. Please help us reach as many patients as possible by keeping your appointment time or giving us plenty of notice if you can't.

Available Appointments*

I am registering for:*

Pfizer Bivalent Booster

Which arm would you like us to use for your vaccination?*

I would also like a second vaccination at this appointment: (optional)

**This 2nd vaccination will be given in the opposite arm chosen above. If this is not possible please let a staff member know**

Name*

First NameLast Name

Patient Email Address*

Date of Birth*

Date

Mother's Maiden Last Name*

Required by Maryland ImmuNet (State of Maryland Vaccine Registry)

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Gender*

Cell Phone Number*

Please enter a valid phone number.

Primary Care Provider (if applicable)

Primary Care Provider City / State (if applicable)

Primary Care Phone # (if known)

Please enter a valid phone number.

Race*

Ethnicity*

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? If Yes, please list the previous doses in the comments.
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?

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 that is available here Pfizer COVID-19 Vaccine Patient Fact Sheet 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.

Signature*

Clear

Date Signed*

Date

There will be no cost to you for your COVID-19 vaccination but the pharmacy will bill for our administration costs. Please select your insurance type below:*

Please Bill My Medicare InsurancePlease Bill My Private or State Medicaid Insurance PlanI don't have insurance but will provide my Social Security Number below so that the the pharmacy can bill the uninsured patient fund

Medicare Part B ID Number

If no insurance please provide your Social Security Number