COVID-19 Vaccination Consent 6PB Riverdale -Adults

Date to be Vaccinated

Mon-Thu 9:00am-9:00 pm, Fridays 10:00am-2:00 pm and Sundays 10:00am-2:00pm and 7:00pm-9:00pm ALL AGES and ALL COVID-19 VACCINES.

Age*

If under 18 must be accompanied by a guardian

Sex assigned at birth*

MaleFemale

Ethnicity*

Race*

Marital Status*

SingleMarried

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number (if a Minor, parent/guardian's phone number)*

Please enter a valid phone number.

E-mail (if a Minor, parent/guardian's e-mail)*

example@example.com

Parent/Guardian Name Filling and signing this consent*

If patient is 17 years of age or younger

Mother's Maiden Name*

If patient is 17 years of age or younger

Mother's Date of Birth*

If patient is 17 years of age or younger

Insurance Company Name*

if uninsured write uninsured

Insurance ID Number*

if uninsured write 0

Do you have a secondary insurance policy?*

Yes, I have a secondary insurance policy (add the name and number above and a picture of both below)No, I have one insurance policy

Photo of Insurance Card*

Browse Files

If not insured just attach picture of an ID

Photo of ID of family member who is the PRIMARY insured *

Browse Files

If not insured attach photo of ID again

Which vaccine are you opting for?*

Pfizer/BiONTechModerna

Which Pfizer vaccine are you opting for?*

Adult Bivalent (12yrs+)Child Bivalent (5-11yrs)Infant Bivalent (6m-4yrs) Dose #3 ONLYAdult Primary (12yrs+): Dose #1 or 2 ONLYChild Primary (5-11yrs): Dose #1 or 2 ONLYInfant Primary (6m-4yrs) Dose #1 or 2 ONLY

Which Moderna vaccine are you opting for?*

Adult Bivalent (12yrs+)Child Bivalent (6-11yrs)Infant Bivalent (6m-5years) Dose #3 ONLYAdult Primary (12yrs+): Dose #1 or 2 ONLYInfant Primary (6m-5yrs) Dose #1 or 2 ONLY

Shot #*

In the last 10 days, have you had a COVID-19 test because you had symptoms and are still awaiting your test results or been told by a health care provider or health department to isolate or quarantine at home due to COVID-19 infection or exposure?*

YesNo

Do you have cancer, leukemia,HIV/AIDS or any other condition that weakens the immune system?*

YesNoUnknown

Are you 18 years old or older AND a resident of a long term facility?*

YesNo

Are you 50 through 64 years old AND have one or more of the following conditions (due to increased risk of moderate or severe illness or death from the virus that causes COVID-19):1.) Cancer (current or in remission, including 9/11-related cancers); 2.) Chronic kidney disease; 3.) Pulmonary Disease, limited to, COPD (chronic obstructive pulmonary disease), asthma (moderate-to-severe), pulmonary fibrosis, cystic fibrosis, tuberculosis, and 9/11 related pulmonary diseases; 4.) Intellectual and Developmental Disabilities including Down Syndrome; 5.) Heart conditions, including but not limited to heart failure, coronary artery disease, cardiomyopathies, or hypertension (high blood pressure); 6.) Immunocompromised state(weakened immune system) including but not limited to solid organ transplant or from blood or bone marrow transplant, immune deficiencies, HIV, use of corticosteroids, use of other immune weakening medicines, or other causes; 7.) Severe Obesity (BMI 40 kg/m2 or higher), Obesity (body mass index [BMI] of 30 kg/m2 or higher but < 40 kg/m2), Overweight (BMI of 25 kg/m2 or higher but < 30kg/m2); 8.) Pregnant or recently pregnant;9.) Sickle cell disease or Thalassemia; 10.) Type 1 or 2 diabetes mellitus; 11.) Cerebrovascular disease (affects blood vessels and blood supply to the brain); 12.) Neurologic conditions including but not limited to Alzheimer's Disease or dementia; 13.) Liver disease limited to cirrhosis, non-alcoholic fatty liver disease, alcoholic liver disease, or autoimmune hepatitis; 14.) Current or former smoker; 15.) Substance use disorder, 16) Mental health disorders limited to mood disorders including depression, schizophrenia spectrum disorders*

YesNoUnknown

Are you 18 through 49 years old AND have one or more of the underlying medical conditionslisted above, and are seeking a booster because the benefits outweigh the risks?*

YesNoUnknown

Are you 18 through 64 years old AND are at increased risk for COVID-19 exposure andtransmission because of working or living in a high-risk setting?*

YesNoUnknown

Have you received 2 doses of the Pfizer vaccine, the second dose being at least 6 months ago?*

YesNo

Have you received 2 doses of the Moderna vaccine, the second dose being at least 6 months ago?*

YesNo

Have you received a dose of the Janssen vaccine, at least 2 months ago?*

YesNo

If you had a previous dose of Janssen (Johnson & Johnson), did you develop thrombosis withthrombocytopenia syndrome (TTS)?*

YesNoUknown

Have you received a previous dose of a COVID-19 vaccine authorized by the WHO but not by the FDA (AstraZeneca – VAXZEVRIA, Sinovac - CORONAVAC, Serum Institute of India – COVISHIELD, Sinopharm/BIBP)?*

YesNoUnknown

Emergency Use Authorization
The FDA has made the COVID-19 vaccine available under an emergency use authorization (EUA). The EUA is used when circumstances exist to justify the emergency use of drugs and biological products during an emergency, such as the COVID-19 pandemic. This vaccine has not undergone the same type of review as an FDA-approved or cleared product. However, the FDA’s decision to make the vaccine available is based on the totality of scientific evidence available, showing that known and potential benefits of the vaccine outweigh the known and potential risks. Please note: FDA approved the Pfizer-BioNTech COVID-19 vaccine as a two-dose series in individuals 5 years of age and older. And for the administration of a third dose in the populations set forth in the consent section below.
Consent
I have read, or had explained to me, the information sheet about the COVID-19 vaccination. I understand that if my vaccine requires two doses, I will need to be administered (given) two doses to be considered fully vaccinated. Further, I understand that a booster dose of COVID-19 vaccine may be recommended at least 2 months following the first dose of Janssen vaccine or at least 5 months following the second dose of PfizerBioNTech or Moderna COVID-19 vaccine if I am a member of a certain population (e.g., 65 years or older, 18 years old or older and a resident of a long term care facility, 50 64 years with an underlying medical condition, 18-49 years old with an underlying medical condition based on individual benefits and risks, 18-64 years old and at an increased risk for COVID-19 exposure and transmission because of working or living in a high-risk setting and based on individual benefits and risks) to increase my protection. I have had a chance to ask questions which were answered to my satisfaction (and ensured the person named above for whom I am authorized to provide surrogate consent was also given a chance to ask questions). I understand the benefits and risks of the vaccination as described. I request that the COVID-19 vaccination be given to me (or the person named above for whom I am authorized to make this request and provide surrogate consent). I understand there will be no cost to me for this vaccine. I understand that APP Health Group will bill my insurance or HRSA for administering the vaccine and any monies or benefits for administering the vaccine will be assigned and transferred to the vaccinating provider, including benefits/monies from my health plan, Medicare or other third parties who are financially responsible for my medical care. I authorize release of all information needed (including but not limited to medical records, copies of claims and itemized bills) to verify payment and as needed for other public health purposes, including reporting to applicable vaccine registries.

By signing this form, I hereby accept that I have read and understood the acknowledgment letter provided above. I declare that the information I have provided above is correct. I am giving my full consent for myself and/or my child to get the COVID-19 vaccine.

Signature

If patient is a Minor consent must be signed by parent/guardian Clear

NOTICE: We are relocating our clinic to 5600 Riverdale Ave Effective Sunday, October 23, 2022