The Pharmacie Shoppe COVID-19 Consent Form

COVID-19 VACCINE CONSENT FORM
At this time we are only offering the Moderna vaccine. If you are looking for the Pfizer or Janssen/Johnson and Johnson COVID-19 vaccine, please do not submit this form.
Name*

First NameLast Name
Email*
example@example.com
Age*
Phone*
Gender at birth*

MaleFemale
Address*

Address

Street Address Line 2

CityState

Zip Code
Race*
Ethnicity*
Primary Care Doctor*
Primary Care Doctor City/State*

Insurance Information
Please select one of the following*

MedicaidMedicare Part BPrivate InsuranceNo Insurance
Provider*
Policy/Member ID #*
Medicaid #*
Group #*
Subscriber*
Responsible Party*
Policy Holder's Date of Birth*

MonthDayYear
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 SecurityState IdentificationDriver'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