SPPHARM - Pfizer AGES 5-11

Vaccine Recipient Name *

First Name Last Name

Vaccine Recipient Physical Address *

Street Address

Street Address Line 2

City State Initials

Postal / Zip Code

Race (Select One): *

Ethnicity (Select One): *

Date of Birth *

Gender *

Vaccine Recipient Phone Number *

Email

example@example.com

Emergency Contact Name *

Relationship to Emergency Contact *

Phone Number of Emergency Contact *

Please select an appointment time: *

**Vaccine supply is limited. Please keep your appointment or call if you need to cancel or change it. If you miss an appointment, no doses will be held to guarantee your dose.**

To ensure adequate vaccine supply, only one patient can be scheduled per appointment slot. If you want to come in with a family member, schedule two consecutive appointments.

COVID-19 Screening Questions *

	Yes	No
1. Have you experienced any of the following symptoms in the past 48 hours: • fever or chills • cough • shortness of breath or difficulty breathing • fatigue • muscle or body aches • headache • new loss of taste or smell • sore throat • congestion or runny nose • nausea or vomiting • diarrhea
2. Within the past 14 days, have you been in close contact with anyone who has COVID-19 or COVID-like symptoms? Or have you been instructed to quarantine? Close contact is being 6 feet or closer for more than 15 minutes with a person, or having direct contact with fluid from a person with COVID-19 (for example, being coughed or sneezed on).
3. Within the last 14 days, have you or anyone in your household tested postive for COVID-19?

COVID-19 Vaccine Screening Questions *

	Yes	No	Don't Know
1. Are you feeling sick today?
2. Have you ever received a dose of COVID-19 Vaccine?
3a. Have you ever had an allergic reaction to a component of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures? Allergic Reaction Defined: This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.
3b. Have you ever had an allergic reaction to Polysorbate?
3c. Have you ever had an allergic reaction to a previous dose of COVID-19 Vaccine?
4. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?
5. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a component of COVID-19 vaccine, polysorbate, or any vaccine or injectable medication? This would include food, pet, environmental, or oral medication allergies.

Check all that apply to you:

	Yes
Have a history of myocarditis or pericarditis
Had COVID-19 AND was treated with monoclonal antibodies or convalescent serum
Have a weakened immune system (i.e. HIV infection, cancer) or take immunosuppressive drugs or therapies
Have a bleeding disorder
Take a blood thinner
Currently pregnant of breastfeeding
History of heparin-induced thrombocytopenia (HIT)
Have received dermal fillers
History of Guillain-Barre Syndrome (GBS)

COVID-19 Vaccine Manufacturer for the first and/or second dose received (do not complete if you selected "no" to #2 above.)

Date of FIRST dose

Date of SECOND 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 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 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 hereby hold harmless Spring Park Pharmacy, and any supervising physicians, employees, and affiliates of these organizations from all responsibility for action that may occur as a result of the vaccination. This release shall be binding upon my heirs, assigns, executors, administrators, and personal representatives.

The vaccine is available at no cost to anyone no matter if insured or uninsured. Please choose one of the following: *

I HAVE INSURANCE. I will bring my prescription and medical insurance cards to my vaccine appointment. I authorize the pharmacy to bill my insurance for the immunization fee. I DO NOT HAVE INSURANCE: I do not have any insurance, including but not limited to, Medicare, Medicaid, or any other private or government-funded benefit plan.

If you DO NOT have insurance, 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

I agree to (please read and select all): *

Arrive to my appointment on time. Location: Spring Park Pharmacy - 4689 Shoreline Drive Suite 100, Spring Park, MN 55384 Bring my insurance cards and identification Wear appropriate clothing (a short-sleeve shirt or undershirt) and a facemask covering my nose and mouth to my appointment Wait in a designated area for 15 or 30 minutes after the immunization, as determined by the pharmacist

Signature of Parent/Guardian signing and receiving the fact sheet on behalf of the patient: *

Clear

Name of person completing and signing the form (ie. parent/guardian name): *

First Name Last Name

Date *

Today's Date

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.

DO NOT SELECT - PHARMACY USE ONLY

DO NO SELECT - PHARMACY USE ONLY

Pfizer/BioNTech COVID-19 Vaccine Consent Form