Pfizer 12 and up Plumsted Pharmacy Covid Vaccine Appointment

Plumsted Pharmacy

Pediatric (3 to 11 Years Old) COVID-19 Vaccination Appointment and Consent Form. Currently, we are providing walk in vaccinations Monday to Friday 12:00 pm to 6:00 pm
Name*

First NameLast Name
Date Of Birth*

MonthDayYear
For Ages 3 to 11. A parent or guardian 18 years or older must be present for the vaccination to be administered. If 12 or older please use standard vaccine form
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Patient Gender *
Race*
Ethnicity*
Email (if none available please call pharmacy at 609-758-8829)*

Confirmation EmailThis must be unique for each patient requesting a vaccine to get confirmation e-mails.
Immunization Screening for Pfizer COVID-19 Vaccination

All patients getting their first dose with Plumsted Pharmacy will have a second dose and appointment automatically reserved. This second appointment will occur 3 weeks from the time of the first dose.
Which pediatric vaccine are you requesting *
Which dose of COVID-19 Vaccine are you getting? *
Date of Dose #1

MonthDayYear
Date of Dose #2

MonthDayYear

Health Screening for Vaccination Eligibility (Answer for Child) *

	Yes	No
Have you had a severe allergic reaction (ex. Anaphylaxis, trouble breathing) to any vaccine or injectable therapy, or a history of anaphylaxis due to any cause?
Have you received any other vaccine within the past 14 days or are scheduled to receive any vaccine in the next 14 days?
Have you received convalescent plasma or monoclonal/polyclonal antibody infusions for COVID-19 within the past 90 days?
Are you currently sick? For example, are you currently experiencing fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, etc?
Do you have a bleeding disorder or are you taking a blood thinner?
Have you tested positive for COVID-19 in the last 10 days?
Are you currently in quarantine for COVID-19 exposure?

Appointment Times Weekdays
Appointment Times Saturday
Insurance / Coverage Information
Insurance Status (PLEASE BRING CARD TO APPOINTMENT)*

Private/Commercial (Prescription Drug Insurance)MedicareMedicaidUn-insured
If Private, Medicare, or Medicaid: Insurance Card (Front Image)

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If Private, Medicare, or Medicaid: Insurance Card (Back Image)

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Card Information for Private/Commercial Insurance (located on front or back of card)

Prescription ID #ID#
Prescription Group IDGroup #
Prescription BIN # Bin #
Prescription PCN # PCN #
Medicare ID
If Un-insured: I attest that I do not have any insurance, including but not limited to Medicare, Medicaid or any other private or government-funded health benefit plan.*
In order to have to your vaccine administration fee paid for by the United States Health Resources & Services Administration’s COVID-19 Program for Uninsured Patients, please provide a valid Social Security number.
I have read, or had explained to me, the information sheet about the COVID-19 vaccination. I understand that if my vaccine requires two doses, I will need to be administered (given) two doses of this vaccine in order for it to be effective. I have had a chance to ask questions which were administered to my satisfaction (and ensured the person named above for whom I am authorized to provide consent was also given a chance to ask questions). I understand there will be no cost to me for this vaccine. I understand that any monies or benefits for administering the vaccine will be assigned and transferred to the vaccinating provider, including benefits/ monies from my health plan, Medicare or other third parties who are financially responsible for my medical care. I authorize release of all information needed (including but not limited to medical records, copies of claims and itemized bills) to verify payment and as needed for other public health purposes, including reporting to applicable vaccine registries. I am authorized to provide consent for the child that will be receiving the COVID-19 Vaccine*

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Plumsted Pharmacy

Immunization Screening for Pfizer COVID-19 Vaccination

Insurance / Coverage Information