Gloyer's Pharmacy COVID-19 Vaccine Consent Form

Vaccine Recipient's Date of Birth: *

Pfizer available for 5 years and older. Moderna and J&J plus all boosters must be 18 years or older.

Vaccine Recipient Name *

First Name Middle Initial Last Name

Parent or Guardian's name (if vaccine recipient is less than 18 years old) *

First Name Last Name

Which vaccine and dose are you registering for? *

Pfizer is available for 5 years and older. Moderna and Johnson & Johnson are indicated for 18 years and older. Vaccine recipient must be 18 years old to receive a booster of any type. As of 10/20/21 the CDC/FDA allow "Mix and Match" for booster doses. The booster dose can be of different manufacturer than previous dose(s).

Which dose are you registering for? *

Vaccine Recipient Physical Address *

Street Address

Street Address Line 2

City State Initials

Zip Code

County of residence:

Gender at birth *

Race *

Ethnicity *

Vaccine Recipient Phone Number *

Vaccine Recipient e-mail address

example@example.com

Mother's Maiden Name *

Required for proper vaccine documentation

Primary Care Provider Name

Emergency Contact Name *

Relationship to Emergency Contact

Phone Number of Emergency Contact *

Which vaccine and dose have you received most recently? *

Select the date of most recent dose selected in previous question *

Date

What type of insurance do you have? *

Medicare Commercial insurance (other than Medicare) Uninsured

Please enter your Social Security number (required for Medicare)

Please enter your Social Security number - This will assist us if we have to search for insurance coverage

Please enter the following information from your PRESCRIPTION insurance card *


BIN (6 digits)
PCN
ID or Member ID
Group or RxGroup

Please type your name exactly as it appears on your red, white and blue Medicare card. *

Please type the number exactly as it appears on your red, white and blue Medicare card. *

Please take a photo of your insurance card.

Please take a photo of your red white and blue Medicare card.

COVID-19 Vaccine Screen Questions *

	Yes	No
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?
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.
6. Have you received any vaccine in the last 14 days?
7. Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19?
8. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? [note: monoclonal antibodies does not include antibiotics that you would be prescribed and filled at a pharmacy]
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?
10. Do you have a bleeding disorder or are you taking a blood thinner?
11. Are you pregnant or breastfeeding?
12. Do you have dermal fillers?
13. Do you have a history of myocarditis or pericarditis?
14. Do you have a history of Gullian Barre Syndrome (GBS)?
15. Have you been diagnosed with Multisystem Inflammatory Syndrome after a COVID19 Infection?

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. 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 understand that at this time, some COVID-19 vaccines require 2 doses given 21-28 days apart dependent on the manufacturer. If this is my first dose of the COVID-19 vaccine and a second dose is required (Pfizer and Moderna only), I intend to receive a second dose of the same vaccine in accordance with the timeframe specified in the fact sheet to complete the series.
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 understand that I will be receiving the vaccination at no cost to me.

The vaccine is available to anyone no matter if insured or uninsured. Please check only one of the following. *

	Check one
If INSURED, check this box attesting to bringing in your prescription and medical insurance cards for your vaccine appointment. By selecting this, you are also authorizing the pharmacy to bill your insurance on your behalf for the immunization – understanding you will not incur any costs.
If UNINSURED, you must check this box to attest that the the following information is true and accurate: I do not have any insurance, including but not limited to, Medicare, Medicaid, or any other private or government-funded benefit plan.

For uninsured patients, 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

Please provide social security number, driver's license or ID number and state of issuance *

Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is less than 18 years old):

Clear

Date Signed

Date