11/30/21 (Tues) - Manchester, 62 School St, Manchester MA (was11/9)

If getting a 3rd Shot or Booster Dose

Pfizer & Moderna must be at least 6 months since your second shot - on/before June 3, 2021
Jannsen/J&J must be at least 2 months since your last shot - on/before Oct 1, 2021

Tues 11/30

4pm-7pm

Sacred Heart Church

62 School St

Manchester, MA

Is this your First, Second or Third Dose?*

First DoseSecond DoseThird Dose / Booster Shot (age 18+ only)

Which Vaccine do you want*

Pediatric Pfizer Vaccine (Age 5+)Pfizer Vaccine (Age 12+)Moderna Vaccine (Age 18+)Janssen / J&J (Age 18+)

Appointment-1*

Appointment-2*

Booster Shot Eligibility

For PFIZER and MODERNA - must be atleast 6+ months since last shot
For JANSSEN / J&J - must be atleast 2+ months since last shot
Eligible to anyone age Age 65+
Eligible to ages 18+ if qualifying with an underlying medical condition: Cancer
Chronic kidney disease
Chronic lung diseases, including COPD (chronic obstructive
pulmonary disease), asthma (moderate-to-severe), interstitial lung
disease, cystic fibrosis, and pulmonary hypertension
Dementia or other neurological conditions
Diabetes (type 1 or type 2)
Down syndrome
Heart conditions (such as heart failure, coronary artery disease,
cardiomyopathies or hypertension)
HIV infection
Immunocompromised state (weakened immune system)
Liver disease
Overweight and obesity
Pregnancy
Sickle cell disease or thalassemia
Smoking, current or former
Solid organ or blood stem cell transplant
Stroke or cerebrovascular disease, which affects blood flow to the
brain Substance use disorders
Elligible to ages 18+ at increased risk for COVID-19 exposure and transmission because of occupational or institutional setting may get a booster shot of Pfizer-BioNTech vaccine based on their individual benefits and risks

First responders (healthcare workers, firefighters, police, congregate care staff)

Education staff

Food and agriculture workers

Manufacturing workers

Corrections workers

US Postal Service workers

Public transit workers

Grocery store workers

*List could be updated in the future

SIGNATURE - I attest that I qualify and am eligible for a 3rd shot based on the above criteria*

Which arm do you want the shot?*

Left DeltoidRight Deltoid

Are you Under the Age of 18?*

YesNo

Name of Parent/Guardian

Phone # of Parent/Guardian

Email of Parent/Guardian

The parent or guardian does NOT need to go with the minor to their vaccination appointment to give consent. Please review the below information and PARENT or GUARDIAN can sign for consent here electronically

Information on the risks and benefits of a COVID-19 Vaccine

Your child is being offered a COVID-19 vaccine made by Pfizer-BioNTech. The PfizerBioNTech COVID-19 Vaccine is approved by the U.S. Food and Drug Administration (FDA) for people over 16 years old, with the brand name Comirnaty. The FDA has also issued an Emergency Use Authorization for Pfizer-BioNTech COVID-19 Vaccine for people ages 5 and older. Both the Pfizer-BioNTech COVID-19 Vaccine and Comirnaty are administered as a 2-dose series, 3 weeks apart, into the muscle.

The vaccine provider will need certain information about your child’s medical history before administering the vaccine. Those questions are available here www.mass.gov/CDCScreeningForm

The vaccine may not protect everyone from COVID-19 disease. Some people may
experience side effects after getting the vaccine. Side effects that have been reported include injection site pain, tiredness, headache, muscle pain, chills, joint pain, fever, injection site swelling, injection site redness, nausea, feeling unwell, and swollen lymph nodes. There is a remote chance that the vaccine could cause a severe allergic reaction. A severe allergic reaction would usually occur within a few minutes to one hour after getting a dose of the vaccine. For this reason, a vaccination provider may ask the person receiving the vaccine to stay at the place where they received their vaccine for monitoring after vaccination. Signs of a severe allergic reaction can include difficulty breathing, swelling of the face and throat, a fast heartbeat, and/or a bad rash all over the body.

Additional information is available in the Pfizer-BioNTech COVID-19 Vaccine “Fact Sheet for Recipients and Caregivers” available at:

• Recipients and Caregivers 5-11 years of age (fda.gov) https://www.fda.gov/media/153717/download
• Recipients and Caregivers 12 years of age and older (fda.gov) https://www.fda.gov/media/153716/download

CONSENT FOR MINOR’S VACCINATION: I have reviewed the information on risks and benefits of the Pfizer-BioNTech COVID-19 Vaccine in Section 2 above and understand the risks and benefits. In providing my consent below, I agree that:

I have reviewed this consent form, and I understand that the “Fact Sheet for Recipients and Caregivers,” includes more detailed information about the potential risks and benefits of the Pfizer-BioNTech COVID-19 Vaccine.
I have the legal authority to consent to have the child named above vaccinated with the Pfizer-BioNTech COVID-19 Vaccine.
I understand I am not required to accompany the child named above to their vaccination appointment and that, by giving my consent below, the child will receive the Pfizer-BioNTech COVID-19 Vaccine whether or not I am present at the vaccination appointment.
If I have health insurance that covers the child named above, I give permission for my insurance company to be billed for the costs of administering the PfizerBioNTech COVID-19 Vaccine. The government is paying for the Pfizer-BioNTech COVID-19 Vaccine itself, and I will not be billed for that portion of the cost of my immunization.
I understand that as required by state law, all immunizations will be reported to the Department of Public Health Massachusetts Immunization Information System (MIIS). I can access the MIIS Fact Sheet for Parents and Patients, at www.mass.gov/dph/miis, for information on the MIIS and what to do if I object to my or my family’s data being shared with other providers in the MIIS.

I GIVE CONSENT for the child named on this form to get vaccinated
with the Pfizer-BioNTech COVID-19 Vaccine and have reviewed and agree to the information provided above. (If this consent is not signed the child will not be vaccinated.)

Signature of Parent or Guardian*

Last Name*

First Name*

Middle Name

Street Address*

Address Line 2

City*

State*

MANHOther

Zip Code*

Date of Birth*

Gender at birth*

Race*

Ethnicity*

Telephone Number*

What is your primary insurance?*

MedicareMassHealthPrivateNo Insurance

Please enter the Medicare Number (from your red white and blue card)

Last 4 numbers of your social security number

Enter Rx Bin #

Enter Rx PCN #

Enter Rx Group #

Enter Rx ID #

Relationship

CardholderSpouse / Domestic PartnerChild / Dependent

Email*

example@example.com

COVID-19 Vaccine Screen Questions*

	Yes	No
1. Are you feeling sick today?
2. Have you ever received a dose of COVID-19 Vaccine?
3. Have you ever had a severe allergic reaction (hives, difficulty breathing)? This could be foods, pets, environmental or medications?
5. Do you use an Epi-pen for anything?
7. Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19?
8. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? [note: monoclonal antibodies does not include antibiotics that you would be prescribed and filled at a pharmacy]

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 after clicking submit), 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. - zero copay

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

Date Signed

Date

Drivers License

Insurance Card

Conformation email will be sent from JotForm.com

COVID-19 Vaccine Clinic Eligibility - Ages 5+

DAY OF THE EVENT

Vaccine Recipient Personal Information

__________COVID-19 Vaccine Clinic__________ Eligibility - Ages 5+

DAY OF THE EVENT

Vaccine Recipient Personal Information

COVID-19 Vaccine Clinic Eligibility - Ages 5+