COVID-19 Vaccine Appointment & Consent Form

PLEASE READ CAREFULLY

The CDC has approved a booster dose for all three COVID-19 Vaccine Products.

Pfizer-BioNTech or Moderna

For individuals who received a Pfizer-BioNTech or Moderna COVID-19 vaccine, all patients age 18 years and older are eligible for a booster shot at 6 months or more after their initial series is complete:

Janssen / Johnson & Johnson

People aged ≥18 years who received a single dose Janssen primary series (1 dose) should receive a COVID-19 booster dose at least 2 months after completing the primary series.

Click Herefor more information on who is eligible for a COVID-19 Vaccine Booster Shot

1. For information regarding the vaccine refer to the link below for the Emergency Use Authorization (EUA) Fact Sheet.

Moderna EUA Fact Sheet

Johnson and Johnson EUA Fact Sheet

2. Select your 15 minute appointment time and complete the form.

3. Make sure a "thank you" screen appears after you click submit

*NOTE we are now located at 213 E Hustan Ave in Fort Pierre (next to Perkins).

Please select your appointment time *

Vaccine Recipient Name *

First Name Middle Initial Last Name

Vaccine Recipient Physical Address *

Street Address

City State Initials

Postal / Zip Code

Date of Birth *

You must be 18 years or older to receive the vaccine

Age

Enter age of vaccine recepient

Gender *

Race *

This information is required for vaccine reporting

Ethnicity *

This information is required for vaccine reporting

Other Names Used (e.g. Maiden name, nickname, etc.)

Required for proper vaccine documentation

Vaccine Recipient Phone Number *

Please enter a valid phone number.

Emergency Contact Name *

Relationship to Emergency Contact *

Phone Number of Emergency Contact *

COVID-19 Vaccine Screening Questions *

	Yes	No
1. Are you feeling sick today?
2. Have you ever received a dose of COVID-19 Vaccine?
3. Are you currently on quarantine due to an exposure to COVID-19?
4. Are you currently on isolation due to being diagnosed with COVID-19 in the last 10 days?
5. Have you received passive antibody therapy (monoclonal antibodies/covalescent serum) as treatment for COVID-19 in the last 90 days? [note: monoclonal antibodies does NOT include antibiotics that you would be prescribed and filled at a pharmacy]
6a. Have you ever had an allergic reaction to a component of the COVID-19 Vaccine, including polyethylene glycol/PEG (found in some medications such as laxatives and preparations for colonoscopy procedures) or Polysorbate?
6b. Have you ever had an allergic reaction/anaphylaxis to a previous dose of COVID-19 Vaccine?
6c. Have you ever had an allergic reaction/anaphylaxis to any other vaccine or injectable medication (intravenous, subcutaneous, or intramuscular)?
7. Do you have a weakened immune system caused by something such as HIV, cancer, or do you take immunosuppressive drugs/therapies (e.g. steroid, chemotherapy, radiation)?
7a. If yes, have you discussed & received counseling regarding the COVID Vaccine from your provider?
8. Are you pregnant or breastfeeding?
8a. If yes, have you discussed & received counseling regarding the COVID Vaccine from your provider?

COVID-19 Vaccine Manufacturer for the first/second dose you received *

Date of first dose *

Date of second dose (if applicable)

If applicable, select the most appropriate statement that determines your eligibility for the booster dose

Which dose you are receiving today? *

If applicable, Immunocompromised patients select the most appropriate statement that defines your eligibility for the additional dose *

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 Moderna Fact Sheet), 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 understand that at this time, the COVID-19 vaccine requires 2 doses given 21-28 days apart depending on the manufacturer. 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 reactions occur.
I understand that I will be receiving the vaccination at no cost to me.
I understand the pharmacy will disclose this immunization record to the State Immunization Registry

The vaccine is available to anyone no matter if insured or uninsured. Please check only one of the following. *

	Check one
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 fee – 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.

Insurance Information

Rx BIN Number

Rx PCN Number/Processor Control Number

Rx Group Number/GRP Number RX ID Number

Medicare Benefits Number

For Medicare Patients Only. Enter letters and numbers as shown in the image.

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

Enter ID number/Drivers License Number/Social Security Number

Enter one of the ID numbers in the box.

Name of Person Completing This Form *

Relationship to Patient (if not patient)

Which arm would you like the vaccination in? *

By signing this form, I attest that all information I have provided on this form is true and accurate, thereby qualifying me to receive a COVID-19 vaccine/booster dose. *

Clear

Date Signed *

Date

Lot Number

Expiration

Moderna COVID-19 Vaccine Consent Form

Complete this online form prior to arriving for your COVID vaccine.