5-11 years Vaccine Appointment

5-11 years Vaccine Appointment

Pfizer Vaccine (ages 5-11 years old)
!!!Please read carefully before scheduling your appointment!!!

On November 2, 2021, the Centers For Disease Control and Prevention and the Advisory Committee on Immunization Practices authorized the use of Pfizer-BioNTech vaccine for ages 5 to 11. The CDC’s recommendations followed the U.S. Food & Drug Administration’s approval to expand the Emergency Use Authorization (EUA) to allow for the Pfizer vaccine to be administered to children in this age group.
Select Vaccine Appointment *
Minor's Name *

First Name Last Name
Minor's Date of Birth *

Month Day Year
Minor's Age *
Parent/Guardian's Name *
Relationship to Parent/Guardian
Parent/Guardian's Phone Number *
Parent/Guardian Phone Number
Parent/Guardian's Email
Note: Confirmation email will go to this email
Address *

Street Address

Street Address Line 2

City State

Zip Code
Minor's Sex *
Minor's Race *
Minor's Ethnicity *
Minor's Mother's Maiden Name *
Required for proper vaccine documentation
Primary Vaccine Site *

Left Deltoid Right Deltoid
Primary Care Provider Name

COVID-19 Vaccine Screening Questions *

	Yes	No	Comments
1. Is your child currently feeling sick or ill?
2. Have you child ever received a dose of COVID-19 Vaccine? If yes, enter the vaccine brand and date in the "Comments" column
3a. Has your child ever had an allergic reaction to: (This would include a server 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 caused hives, swelling, or respiratory distress, including wheezing)
3b. Has your child ever had an allergic reaction to a component of a COVID-19 vaccine, including any of the following: 1. Polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedure? 2. Polysorbate, which is found in some vaccines, film coated tablets, and intravenous steroids? 3. 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? (This would include a server 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 caused hives, swelling, or respiratory distress, including wheezing)
5. Has your child had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19 in the past 30 days?
6. Has your child received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?
7. Did your child receive any vaccine in the last 14 days?
8. Does your child have an history of myocarditis or endocarditis?
9. Does your child have a weakened immune system (i.e. HIV infection, cancer)?
10. Does your child have a history of Guillain-Barre syndrome (GBS)
11. Is the child pregnant or breastfeeding?
12. Does the child takes immunosuppressive drugs or therapies? or have a weakened immune system?

Consent (check each box below after reading and prior to signing the form) *

	Accept
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet (the Pfizer 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 understand that my child will be receiving the vaccination at no cost to me.
I authorize Crofton Pharmacy to administer Pfizer covid-19 vaccine to my Child/Children.

Signature of Parent/Guardian to Receive Vaccine & EUA /VIS: *

Clear
Please bring active prescription insurance card for clients receiving vaccine and in case of uninsured copy of parent's or guardian's state issued ID will be required at time of an appointment.
Should be Empty:

5-11 years Vaccine Appointment

!!!Please read carefully before scheduling your appointment!!!