Vaccine Consent Form
* Please fill out the required details below
Section I. Personal Information
Patient's Full Name:
*
First Name
Ml
Last Name
Date of Birth:
*
/
Month
/
Day
Year
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
Other
Address:
Street Address Line 2
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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. COVID VACCINE IS TEMPORALY UNAVAILABLE.
*
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 last dose of covid shot?
-
Month
-
Day
Year
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.
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Cancel
of
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
Other
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
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Month
-
Day
Year
Date Picker Icon
Time
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
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.
Submit
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