WCC Moderna Push UNIVERSAL ALL DOSES 12+

All COVID Vaccines for Patients 12+

Please read this entirely and fill out the required details below. This form is HIPAA Compliant.
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CLINIC LOCATION

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56 Rock City Road, Woodstock, NY 12498

CLINIC DATE AND TIME

Wednesday 10-27-21 from 3-6:30p

Friday 10-29-21 from 3-6:30p
This clinic is for ALL DOSES of JJ, Pfizer or Moderna vaccine including boosters.

Patients 12-17: Pfizer only

Patients 18+: Moderna, JJ or Pfizer

BOOSTER DOSES AVAILABLE

Moderna, Pfizer and JJ booster doses have been approved for select populations—including teachers, students, and school staff.

Please visit drneal.co/booster for information about your booster eligibility, mix-and-match, and more BEFORE signing up.

MINORS MUST BE ACCOMPANIED BY A PARENT OR LEGAL GUARDIAN
ALL PATIENTS ARE REQUIRED TO BRING PROOF OF AGE.

Here are acceptable forms of ID per NYS:
• Driver’s license or non-driver ID;
• Birth certificate issued by a state or local government;
• Current U.S passport or valid foreign passport;
• Permanent resident card;
• Certificate of Naturalization or Citizenship;
• Life insurance policy with birthdate; or
• Marriage certificate with birthdate
Doses Available:

1000

(We may add more as we can! JJ SUPPLY VERY LIMITED!!!!)
Which COVID vaccine would you like?*

Pfizer FirstPfizer SecondPfizer BoosterModerna FirstModerna SecondModerna Third Dose for Immunocompromised PatientsModerna Booster Dose (1/2 dose)JJ First DoseJJ Booster Dose
Section I. Personal Information
Date of Birth*

MonthDayYear
Date
When entering your name, do NOT write middle initials. PLEASE write any suffix (Jr, III).
Patient LEGAL First Name ONLY*
Patient LEGAL Last Name ONLY*
Biological Sex:*

MaleFemaleOther
Phone Number:*
Email*

Confirmation Emailexample@example.com
Address Information

ATTENTION: If you are a college student, please enter the address that is associated with your insurance (usually a HOME address). Otherwise, use your COLLEGE address.

If you are an international student, please use your COLLEGE address.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Which of the following best describes your ethnic group?*

Hispanic or LatinoNot Hispanic or LatinoOther / Unknown / Prefer not to answer
Which of the following best describes your race?*

Native AmericanAlaska NativeAsianBlack or African AmericanNative HawaiianOther Pacific IslanderWhiteOther / Unknown / Prefer not to answer
Primary Care Doctor:*
Doctor City/State:*
Do you have any allergies to medicines?*

No known drug allergiesYes (enter them below)
Please enter any and all drug or food allergies:
Section II. Questionnaire for Immunization

Please select the correct option below:*

	Yes	No	Don't know or N/A
In the past two weeks, have you tested positive for COVID-19 or are you currently being monitored for COVID-19?
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, headache, new loss of taste or smell, sore throat, nausea, vomiting, or diarrhea?
Have you ever had a serious or life-threatening allergic reaction (hives, difficulty breathing) to any vaccine or shot?
Do you carry an EpiPen?

Section III. Signatures

In an attempt to reduce paper waste, all legally required documents must be downloaded here. Very limited copies will be available on clinic day.

If you are completing this on behalf of someone else, please download these documents and email them to the patient.

If they do not have email, limited copies will be available for them on clinic day.

All copies are available at drneal.co/vax.

REQUIRED DOCUMENTS:

Please download the EUA for the vaccine you are signing up for:
- PFIZER VACCINE: Click this to download the Emergency Use Authorization for the Pfizer Vaccine.
- MODERNA VACCINE: Click this to download the Emergency Use Authorization for the Moderna Vaccine.
- JOHNSON & JOHNSON VACCINE: Click this to download the Emergency Use Authorization for the J&J Vaccine.
All Patients

Click this to download the Notice of Privacy Practices

Click this to download the CDC vSafe app flyer

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 registration.

I 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.

I certify that I have received, read, and understand the Emergency Use Authorization.

I certifty that I have received the Notice of Privacy Practices.

I certify that I have received the CDC vSafe informational flyer.

Please type your full name in the box below. You agree your typed full name represents your electronic signature is the legal equivalent of your manual signature on this form.
Type Your Full Name as Electronic Signature*
Provider Service for Immunization

This vaccine is provided FREE OF CHARGE to all. Providers will be reimbursed for the administration of the vaccine via two sources: private insurance for those who have it, or directly from the federal government if someone is uninsured.
By signing up for immunization with Village Apothecary (and Dr. Neal Smoller, PharmD), you are agreeing to provide your insurance or identifying information AND are willing to provide verification of any incomplete information at a later date IF a staff member reaches out to you.
Are you currently insured via Medicare, Medicaid, Tricare, or Private Insurer?*

YesNo
Insurance Billing for the Administration of the Vaccine*

I will bring my PHARMACY BENEFITS insurance information to the clinic, and I authorize the pharmacy to bill my insurance on my behalf for the immunization. I understand this vaccine will have no cost to me.
If uninsured, you must check the box below to attest that 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 health benefit plan
In order to have your vaccine administration fee paid for by the United States Health Resources & Services Administration's COVID-19 Program for uninsured patients, please select to provide one of the following:*

Social Security NumberState identification number and state of issuanceDriver's license number and state of issuance
Social Security Number*
State identification number and state of issuance*
Driver's license number and state of issuance*
IF YOU ARE INSURED, PLEASE BRING YOUR INSURANCE CARD THAT HAS YOUR PHARMACY BENEFITS INCLUDED ON IT.

This could be:
- Medicare Part B
- Caremark
- Express Scripts
- Optum
- Or any card that has an RxBIN number on it!
TRICARE BENEFICIARIES: We need the SSN of the military member on clinic day.
Section IV. Appointment Confirmation

Pick the day you wish to attend, then the time.
Choose Your Appointment Time:*
By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.
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All COVID Vaccines for Patients 12+

Section I. Personal Information

Address Information

Section II. Questionnaire for Immunization

Section III. Signatures

Provider Service for Immunization

Section IV. Appointment Confirmation