COVID-19 Consent Form

Insurance Information
Please select one of the following *

Medicaid Medicare Part B Private Insurance No Insurance
Provider *
Policy/Member ID # *
Medicaid # *
Group # *
Subscriber *
Responsible Party *
Policy Holder's Date of Birth *

Month Day Year
Date
Subscriber ID *
Insurer *
Bin # *
PCN *
Group # *
To have your vaccine administration fee paid for by the United States Health Resources & Services administration's COVID-19 Program for uninsured patients, please provide one of the following: *

Social Security State Identification Driver's License
Social Security # *
State Identification # *
State of Issuance *
Driver's License # *
State of Issuance *

ACKNOWLEDGEMENTS

I understand the benefits and risks of the vaccination(s) as described in the Vaccine Information Sheet (VIS) or Emergency Use Authorization (EUA), a copy of which I was provided with this Consent & 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 that I am authorized to sign this Consent & Release. I have received a copy of the notice of Privacy Practices. 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 & 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 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.
Pfizer Vaccine Information Sheet (VIS)

Pharmacy Notice of Privacy Practices
Moderna Emergency Use Authorization (EUA)

Pharmacy Notice of Privacy Practices
Janssen/Johnson and Johnson Emergency Use Authorization (EUA)

Pharmacy Notice of Privacy Practices
Signature of patient to receive vaccine (or signature of power of attorney or legal guardian) *

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COVID-19 VACCINE CONSENT FORM