Sharpsburg Pharmacy *PEDIATRIC* MODERNA COVID-19 Bivalent Consent Form

17316 Shepherdstown Pike
Sharpsburg, MD 21782
p: 301.432.7223 - f: 301.432.4423
www.sharpsburgpharmacy.com

Thank you for your interest in scheduling a Pediatric COVID-19 Vaccine at Sharpsburg Pharmacy! Currently due to ordering restrictions, we only have Moderna Bivalent boosters available and are unable stock vaccine for primary (1st and 2nd) doses. To receive this vaccine your child must be between the ages of 6 and 11 years old. If your child is 12 or older please use the Pfizer or Moderna vaccine forms to register. Please DO NOT schedule an appointment if you want a different vaccine because other vaccines appointments cannot be scheduled through this form.

Starting 10/12/22:

CDC recommends a Moderna Bivalent Booster dose for:

Children 6-11 who completed the initial vaccine series at least 2 months prior.

Please review the Patient Emergency Use Authorization handout by clicking here prior to your arrival so that we may answer any questions that you have.

If all the appointment times below are grayed out, they have been taken. Please keep checking back because we will open more times as vaccine becomes available to us.

We recommend that you make a NOTE of your APPOINTMENT Date and Time and DOWNLOAD/PRINT the PDF form for your records once you hit submit. You may do this on the "Thank You" page that appears after the form is submitted successfully. Please bring this and any insurance cards with you for the appointment. An email confirmation of the appointment will be sent but many email providers send Jotform emails to their spam or junk mail folders. Please check these folders before calling the store to confirm.

Please complete the questions below.

If you are unable to select a vaccine appointment time below we are currently full, and please check back regularly. If you are local to Sharpsburg and flexible with timing, please call the store for your child to be placed on our wait list for cancellations. Please note that we will call wait list patients on short notice and you must be able to come to the pharmacy quickly to help us prevent wasted vaccine.

If you need to cancel an appointment, please call us so that we can open the spot up for someone else. No shows for appointments can mean that we have to waste a dose that day. Please help us reach as many patients as possible by keeping the appointment time or giving us plenty of notice if you cannot.

Available Appointments*

I am registering my child for:*

Moderna Bivalent Booster (age 6-11)

Which arm would you like us to use for your child's vaccination?

Childs Name*

First NameLast Name

Parent or Legal Guardian

First NameLast Name

Parent/Guardian Email Address*

Childs Date of Birth*

Date

Mother's Maiden Last Name*

Required by Maryland ImmuNet (State of Maryland Vaccine Registry)

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Gender*

Parent/Guardian Cell Phone Number*

Please enter a valid phone number.

Childs Primary Care Provider (if applicable)

Primary Care Provider City / State (if applicable)

Primary Care Phone # (if known)

Please enter a valid phone number.

Race*

Ethnicity*

Have you Screening Questions - if you answer "yes" please include details in the comment section*

	YES	NO	Unsure
Does your child feel sick today?
Has your child received a dose of COVID-19 vaccine before today? If Yes, please list the previous doses in the comments.
Has your child ever had a serious allergic reaction to something? (ie. that you needed an "Epi-Pen" or had to go to the hospital) *You will be required to stay for 30 min after your vaccine
Has your child received another (non-COVID) vaccine in the last 14 days? If Yes, please put name in comments
Has your child ever had a severe allergic reaction after receiving another vaccine or injectable medication? If yes, please enter name in comments and you will be required to stay for 30 min after your vaccine)
Has your child had a positive test for COVID-19 in the last 90 days?
Has your child received monoclonal antibodies or convalescent plasma as treatment for COVID-19 in the last 90 days?
Does your child have a weakened immune system caused by a medical condition (HIV, cancer, etc) or immunosuppressive drug therapy?

Comments to any Yes Answers

*Persons who have had a severe reaction to a vaccine or currently have an acute febrile illness should not receive a vaccine. I consent to the staff to adminster the vaccination(s) mentioned below to my child. I understand that this vaccine has been authorized by the FDA under an Emergency Use Authorization and I have reviewed the fact sheet that is available here Pfizer COVID-19 Vaccine Patient Fact Sheet concerning the specific manufacturer of the vaccine my child is receiving. I understand the benefits and risks of receiving this vaccine and choose to assume this risk. I fully release and discharge the pharmacist and the pharmacy, its affiliations and their officers and employees from any illness, injury, loss, or damage that may result there from. I acknowledge that I have received a copy of the pharmacy's privacy policies according to HIPAA. I assign payment of authorized insurance benefits due to me to be paid to the pharmacy. I consent the release of medical information when necessary for billing, reimbursement, and medical protocol. I also allow for the pharmacy to report any vaccinations received to the appropriate state vaccine registry. I am aware that an immunization certified student pharmacist might be administering this vaccine. I agree to wait near the vaccination area for a minimum of 15 minutes or as otherwise instructed by the pharmacist so that my child may receive treatment if my child begins to feel unwell.

Signature of Parent or Legal Guardian*

Clear

Date Signed*

Date

There will be no cost to you for your COVID-19 vaccination but the pharmacy will bill for our administration costs. Please select your insurance type below:*

Please Bill My Private or State Medicaid Insurance PlanI don't have insurance but will provide my Social Security Number below so that the the pharmacy can bill the uninsured patient fund

If no insurance please provide your Social Security Number