Bell's Family Pharmacy COVID-19 Immunization Questionnaire and Consent Form

Bell's Family COVID-19 Immunization Questionnaire and Consent FormPharmacy Bell's Family Pharmacy
Patient's Full Name *
Date of Birth *
Age *
Address *

Address

Street Address Line 2

City State
Zip *
Phone *
Email *
example@example.com
Gender *

Male Female Other
Ethnicity *

Hispanic/Latino Non-Hispanic/Latino Unknown Prefer not to answer
Race *

African American American Indian Asian Caucasian Native Hawaiian/Other Pacific Islander Prefer not to answer Other:
Primary Doctor *
Doctor's Address *
Emergency Contact *
Relationship to Emergency Contact *
Emergency Contact's Phone Number *
What dose of COVID-19 vaccine will this be? *

First Second Third Fourth
If second or third When did you receive your first dose? *
Which vaccine did you receive? *

Pfizer Moderna Other
By providing your email address you are agreeing to receive information via email from Bell's Family Pharmacy. You may opt out of the email communicationsatany time. We value your privacy and, as a result, we will never share or sell your information with any outside manufacturers or marketers

Answer the following questions:

	Yes	No	Don't Know
In the past two weeks, have you had a known exposure with anyone who tested positive for COVID-19?
Have you had a new onset of fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headaches, new loss of taste or smell, sore throat, nausea, vomiting, or diarrhea?
Are you feeling sick today?
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 & preparations for colonoscopy procedures?
Have you ever had an allergic reaction* to polysorbate?
Have you ever had an allergic reaction* to a previous dose of COVID-19 vaccine?
Have you ever had an allergic reaction* to another vaccine (other than COVID-19 vaccine) or an injectable medication?
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.
Do you carry an EpiPen®?
Have you received any vaccine in the last 14 days?
Have you ever had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?
Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?
Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
Have you ever had a seizure, brain disorder, or Guillain-Barre Syndrome?
Do you have a bleeding disorder or are you taking a blood thinner?
For women: Are you pregnant or breastfeeding, or are you planning to become pregnant in the next month?

I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA), a copy of which I was provided with this Consent and Release. 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 and for whom I am authorized to sign this Consent and Release.
Signature of Person to Receive Vaccine

Clear
Date *

Month Day Year
Date
I have received a copy of the notice of Privacy Practices. | understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the Pharmacy and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.
Signature of Acknowledgement of Notice of Privacy Practices

Clear
Date *

Month Day Year
Date
INSURANCE

I authorize the pharmacy to bill my insurance on my behalf for the immunization
Insurer
Subscriber ID
Bin #
PCN
Group #
Responsible Party
Subscriber ID #
Policy Holder's Date of Birth

Month Day Year
Date
Provider
Policy/Member ID #
Medicaid #
Group #
Administration's COVID-19 Program for uninsured patients, please select to provide one of the following: (Single Choice)
Social Security Number
State identification number
State of Issuance
Driver's license number
State of Issuance
For Pharmacy Use Only
I have reviewed Patient Information and Questionnaire for Immunization with the patient prior to administering the vaccine, and they have

indicated that all answers are accurate as of the day of administration.
Vaccine Manufacturer
Vaccine Lot Number
Expiration Date

Month Day Year
Date
Time Removed from 80°C
Date Removed

Month Day Year
Date
Dosage
Injection Site
Signature of Pharmacist who Administered Vaccine

Clear
Pharmacist Name
Date Administered

Month Day Year
Date
Time Administered
Should be Empty:

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Bell's Family COVID-19 Immunization Questionnaire and Consent FormPharmacy Bell's Family Pharmacy

For Pharmacy Use Only