Consent for COVID-19 Vaccines
Name
First name
Last name
Date of birth
/
Month
/
Day
Year
Date
Gender
*
Female
Male
Phone Number
Please enter a valid phone number.
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Social Security Number or Medicare Number (if available)
Race
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Black or African American
White
Unknown
Other
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Unknown Ethnicity
Which Vaccine Manufacturer are coming for today?
Moderna
Pfizer (BioNTech)
Novavax
What dose number are you coming for today:
Please Select
1st Dose
2nd Dose
3rd Dose (Booster)
4th Dose (Booster)
Date of Last Dose (if known)
-
Month
-
Day
Year
Date
Are you interested in also getting a FLU Vaccine today?
Please Select
Yes
No
The following questions will help us det
ermine your el
igib
ility to be vaccinated today.
1. Do you feel sick today?
*
Yes
No
Don't Know
2. Have you been diagnosed with or tested positive for COVID-19 in the last 14 days?
*
Yes
No
Don't Know
3. In the past 14 days have you been identified as a close contact to someone with COVID-19?
*
Yes
No
Don't Know
4. Have you ever received a dose of COVID-19 vaccine?
*
Yes
No
Don't Know
5. Do you have a history of allergic reaction or allergies to latex, medications, food or vaccines (examples: polyethylene glycol, polysorbate, eggs, bovine protein, gelatin, gentamicin, polymyxin, neomycin, phenol, yeast or thimerosal)?e a question
Yes
No
Don't Know
If yes, please list
6. Have you ever had a reaction after receiving a vaccination, including fainting or feeling dizzy?
*
Yes
No
Don't Know
7. Do you have Derma Fillers?
*
Yes
No
Don't Know
8. Have you received any vaccinations or skin tests in the past eight weeks?
Yes
No
Don't Know
If yes, please list
9. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
*
Yes
No
Don't Know
10. Do you have a bleeding disorder or are you taking a blood thinner?
*
Yes
No
Don't Know
11. For women: Are you pregnant or considering becoming pregnant in the next month?
Yes
No
Don't Know
12. Have you treated with antibody therapy specifically for COVID-19 (monoclonal antibodies or convalescent plasma)?
Yes
No
Don't Know
I certify that I am: (a) the patient and at least 18 years of age; (b) the legal guardian of the patient; or (c) a person authorized to consent on behalf of the patient where the patient is not otherwise competent orunabletoconsent forthemselves. Further, I hereby give my consent to the pharmacy and the licensed healthcare professional administering the vaccine, as applicable (each an "applicable Provider"), to administer the vaccine(s) I have requested above. I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccine(s I understand the risks and benefits associatedwiththeabovevaccine(s)and have readand/orhad explained to me the EUA Fact Sheet on the vaccine(s) I have elected to receive. I also acknowledge that I have had a chance to ask questions and that such questions were answered to my received, satisfaction. Further, I acknowledge that I have been advised that the patient should remain near the vaccination location for observation for approximately 15 minutes after administration. On behalf ofthepatient,thepatient's heirs and personal representatives, I hereby release and hold harmless each applicable Provider, its staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the vaccine(s) listed above. I acknowledge that: (a) I understand the purposes/benefits of my state's vaccination registry ("State Registry") and my state's health information exchange ("State HIE"); and (b) the applicable Provider may disclose my vaccination information to the State Registry, to the State HIE, or through the StateStateany state or federal governmental agencies or authorities ("Government Agencies"), such as state, county, or local Departments of Health or the federal Department of Health and Human HIEtotheRegistry,orto Services, the Centers for Disease Control and Prevention, or their respective designees as may be required by law, for purposes of public health reporting, or to my healthcare providers enrolled in the State Registry and/or State HIE for purposes of care coordination. I acknowledge that, depending upon my state's law, I may prevent, by using a state-approved opt-out form or, as permitted by my state law, an opt-out form ("Opt-Out Form") furnished by the applicable Provider: (a) the disclosure of my vaccination information by the applicable Provider to the State HIE and/or State Registry; or (b) the State HIE and/or State Registry from sharing my vaccination information with any of my other healthcare providers enrolled in the State Registry and/or State HIE. The applicable Provider will, if my state permits, provide me with an Opt-Out Form. I understand that, depending on my state's law, I needspecificallyconsent, and, to the extent required by my state's law, by signing below, I hereby do consent to the applicable Provider reporting my vaccination information to the Government Agencies, State HIE, to may HIE the orthroughStateand/or State Registry to the entities and for the purposes described in this Informed Consent form. Unless I provide the applicable Provider with a signed Opt-Out Form, I understand that my consent will remain in effect until I withdraw my permission and that I may withdraw my consent by providing a completed Opt-Out Form to the applicable Provider and/or my State HIE, as applicable. I understand that even if do not orifI withdrawconsent, my state's laws or federal law may permit certain disclosures of my vaccination information to or through the State HIE or to Government Agencies as required or permitted by law. I further consent my authorize the applicable Provider to: (a) release my medical other information,including any communicable disease (including HIV)and mental health information, to, or through, the State HIE or Government Agencies to my healthcare professionals, Medicare, Medicaid, or other third-party payer as necessary to effectuate care or payment; (b) submit a claim to my insurer for the above requested items and services; and (c) request payment be ofbenefitsmade on my behalf to the applicable Provider with respect to the above requested items and services. I further agree to be fully financially responsible for any cost-sharing amounts, including copays, authorized coinsurance and deductibles, for the requested items and services, as well as for any requested items and services not covered by my insurance benefits. I understand that any payment for which I am financially responsible is due at the time of service or, if the applicable Provider invoices me after the time of service, upon receipt of such invoice. Pharmacy or its affiliates may contact you, including by autodialed and prerecorded calls and texts, at any time, using the contact information provided in your patient record regarding health and safety matters, such as vaccine reminders. By signing below I certify that I am eligible to receive this vaccine as per all local, state, and federal CDC guidelines.
Patient signature (Parent or gaurdian, if minor)
Date
/
Month
/
Day
Year
Date
Do you have health insurance?
*
Yes
No
By signing below I attest that I do not have any medical or pharmacy insurance.
Please upload a Photo ID such as driver license or passport copy if available. (By uploading your ID now will reduce your wait time in the pharmacy) Please also bring in original at time of vaccination.
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Are you able to upload your insurance card online or would you like to enter the insurance information manually
I would like to upload my insurance card
I would like to manually enter my insurance information.
Please either upload a picture of your prescription insurance card or enter the insurance information below. Please also bring in original at time of vaccination.
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Please enter your prescription card information below if your are not able to upload the card:
Name of Prescription Insurance Carrier
RX BIN NUMBER from Insurance Card
RX PCN Number from Insurance Card
RX GROUP Number from Insurance Card
ID Number from Insurance Card
PLEASE BRING YOUR INSURANCE CARD, A PHOTO ID AND YOUR CURRENT VACCINATION CARD INTO THE PHARMACY.
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