1st DOSE October-December

1st Dose COVID-19 Vaccine

Welcome! Visit this link https://www.phila.gov/programs/coronavirus-disease-2019-covid-19/guidance/faq/#vaccines for more information.

Completing this form will allow you to schedule an appointment to receive the COVID-19 vaccine at

Fairmount Pharmacy

1900 Green Street

Philadelphia, PA, 19130

PLEASE BRING YOUR INSURANCE CARD AND ID.

PLEASE WEAR SHORT SLEEVES FOR EASE OF ACCESS TO INJECTION SITE.

AFTER SUCCESSFULLY SUBMITTING YOUR FORM YOU WILL RECEIVE A CONFIRMATION MESSAGE ON THE SCREEN. THIS IS THE ONLY CONFIRMATION YOU WILL RECEIVE.

YOU WILL NOT RECEIVE AN EMAIL CONFIRMATION

We look forward to seeing you!

We are currently vaccinating according to the city of Philadelphia guidelines (link above). Do you qualify for the vaccine at this time based on this information?*

Yes

Please record the date and time of your appointment.

You will not receive any confirmation with this information!

Appointment*

Vaccine Recipient First Name*

Vaccine Recipient Last Name*

Gender*

Date of Birth*

Date

Vaccine Recipient Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

In which arm would you like to receive your COVID-19 vaccine?*

Left ArmRight Arm

Which dose of the COVID-19 vaccine will you receive today?*

First Dose

Vaccine Recipient Phone Number*

Cell phone preferred.

E-Mail Address

Race*

Ethnicity*

Emergency Contact Name*

Relationship to Emergency Contact*

Phone Number of Emergency Contact*

Please enter a valid phone number.

If patient is a minor, please complete the following.

Parent/Guardian First NameParent/Guardian Last Name

COVID-19 Vaccine Screening Questions*

	Yes	No
1. Are you feeling sick today? NOTE: If you answer YES to this question, do NOT schedule your appointment until you have received clearance from your medical professional.
2. Have you ever received a dose of COVID-19 Vaccine? NOTE: If you answer YES to this question, you can not be vaccinated.
3. 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 -or- Polysorbate -or- a previous dose of COVID-19 vaccine NOTE: If you answer YES to this question, do NOT schedule your appointment until you have received clearance from your medical professional.
4. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine or an injectable medication? NOTE: If you answer YES to this question, do NOT schedule your appointment until you have received clearance from your medical professional.
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. NOTE: If you answer YES to this question, do NOT schedule your appointment until you have received clearance from your medical professional.
6. Have you received any vaccine in the last 14 days? NOTE: If you answer YES to this question, do NOT schedule your appointment until you have received clearance from your medical professional.
7. Have you ever had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19? NOTE: If you answer YES to this question, do NOT schedule your appointment until you have received clearance from your medical professional.
8. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? NOTE: If you answer YES to this question, do NOT schedule your appointment until you have received clearance from your medical professional.
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? NOTE: If you answer YES to this question, do NOT schedule your appointment until you have received clearance from your medical professional.
10. Do you have a bleeding disorder or are you taking a blood thinner? NOTE: If you answer YES to this question, do NOT schedule your appointment until you have received clearance from your medical professional.
11. Are you pregnant or breastfeeding? NOTE: If you answer YES to this question, do NOT schedule your appointment until you have received clearance from your medical professional.

Consent (check each box below after reading and prior to signing the form*

	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 Pfizer Fact Sheet is available herein - https://www.fda.gov/media/144414/download. I request the vaccine to be given to me.
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 at this time, the COVID-19 vaccine requires 2 doses given 21-42 days apart for the Pfizer vaccine. My second appointment will be scheduled 21-42 days from the date I receive my first dose.
I understand that I will be receiving the vaccination at no cost to me.

Do you have Medicare Part B (Medical) coverage? (Yes or No)*

Please enter your name exactly as it appears on your Medicare Part B insurance card (red, white, and blue card). If not applicable, write NA*

Please enter your Medicare Number as highlighted in the sample above. If not applicable, write NA.*

Enter Prescription Insurance Card Company Name. If Medicare provided, write NA.*

Aetna, Blue Cross, etc.

Relationship to cardholder.

e.g. self, spouse, child

Enter your ID Number from your Prescription (Rx) Insurance Card. If Medicare is provided, write NA.*

e.g. DZW920000000

Enter your BIN Number from your Prescription (Rx) Insurance Card. If Medicare is provided, write NA. *

e.g. 610623

Enter your PCN from your Prescription (Rx) Insurance Card. If Medicare is provided, write NA.*

e.g. 02050000

Enter your Group from your Prescription (Rx) Insurance Card. If Medicare is provided, write NA.*

e.g. RX4655

Please upload an image of your insurance card (front). If you have difficulty doing this, skip this upload step, and please bring your card with you either way.

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AFTER SUCCESSFULLY SUBMITTING YOUR FORM YOU WILL RECEIVE A THANK YOU CONFIRMATION MESSAGE ON THE SCREEN. THIS IS THE ONLY CONFIRMATION YOU WILL RECEIVE.

YOU WILL NOT RECEIVE AN EMAIL CONFIRMATION

Signature of Person to Receive Vaccine & EUA/VIS (or Signature of Parent/Guardian if Patient is < 18 years old):*

Clear

Date Signed*

Date