COVID Vaccine Consent Form

Please fill out the form below to make an appointment for you COVID-19 and other vaccines.
We have all vaccines in stock.
- Pfizer (both >12 years old and 5-11 years doses)
- Moderna
- Janssen (J&J)
- Influezna (regular and 65+)
- Shingles
What to bring to the appointment
- Your ID (not required but helpful)
- RX insurance card (not required but helpful)
- Medicare A/B card (if you have one)
- Wear clothing that will allow access to your upper arm.
Fields with a Red Star next them are required.
If you have any questions or are unable to fill out the form then, please call us at (781) 349-8895.

Section I. Personal Information

Patient's Full Name: *

First Name Ml Last Name

Date of Birth: *

Age: *

Phone Number: *

Email *

example@example.com

Not Used - do not delete.

Sex at Birth: *

Male Female

Ethnicity:

Hispanic or Latino Non Hispanic/Latino Unknown Prefer not to answer

Race:

African American American Indian Asian Caucasian Native Hawaiian/Other Pacific Islander Prefer not to answer

Address:

Street Address Line 2

Primary Care Doctor:

Doctor City/State:

Which vaccine would you like to get at your appointment? You may get your COVID-19 and Flu vaccines on the same appointment. *

Pfizer Adult (>12 years old) Pfizer Pediatric (5-11 years old) Pfizer Booster Moderna (regular) Moderna Booster (1/2 dose) Janssen J&J Flu Vaccine (9-64 year old) Flu Vaccine (65+) Shingles Vaccine

Are you one of the following?

Essential Worker First Responder Healthcare Worker Person age 65+ Person with chronic condition Resident of a care facility or other group setting No, I am not any of the above

Please specify chronic condition:

https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html?utm_medium=email&utm_source=govdelivery

What dose of COVID-19 vaccine will this be? *

First Dose Second Dose Third Dose / Booster Dose

When did you receive your first dose?

Date

When did you receive your second dose?

Date

Section II. Questionnaire for Immunization

Please select the correct option below:

	Yes	No	Don't know or N/A
Questionnaire for Immunization: Do you feel sick today?
Do you have an allergy to medications, foods, or any vaccines (eggs, gelatin, thimerosal, neomycin, gentamicin, latex, aluminum, preservatives, baker's yeast, etc.)?
Do you carry an EpiPen?
Have you ever had a serious reaction or fainted after receiving any vaccination?
Have you received any other immunizations in the last 14 days?
For women: Are you pregnant or are you planning on becoming pregnant during the next month?
Have you had an allergic reaction to Polyethylene glycol (peg) or Polysorbate?

Please specify the allergy from Q2:

Section III. Appointment Scheduler

**Vaccine supply is limited. Please keep your appointment or call if you need to cancel or change it. Additionally, due to vaccine requirements; we may call you to see if you can come earlier, later or to a nearby location. If you miss an appointment, no doses will be held to guarantee your dose.**

Please pick a day and time for your vaccination *

Section IV. Signatures I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) (insert link to EUA), a copy of which I was provided with this Consent and Release. 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 and Release.

Signature of Person to Receive Vaccine & EUA/VIS (or Signature of Parent/Guardian if Patient is < 18 yo)

Clear

I have received a copy of the notice of Privacy Practices. I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.

Signature of Acknowledgment of Notice of Privacy Practices:

Clear

Please take or upload pictures of front & back of pharmacy benefits insurance card and your Medicare B card. If you do not have a Medicare B card than just your Rx card.

Browse Files

I authorize the pharmacy to bill my insurance on my behalf for the immunization and the information provided is true and accurate.

Medicare Part B Number:

Please enter your Medicare Part B number even if you have Medicare Advantage or other insurance.

If uninsured, you must check the box below to attest that 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 health benefit plan I will pay out-of-pocket for all none COVID-19 vaccines

In order to have your vaccine administration fee paid for by the United States Health Resources & Services Administration's COVID-19 Program for uninsured patients, please select to provide one of the following:

Social Security Number Drivers License or State ID number and the state of issuance

Date

Month Day Year

Time

: Hour Minutes AM/PM Option

Social Security Number

Drivers License Number or State ID number and state of issuance

Type in the ID then space and the state that issued you the ID.

By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.