COVID-19 INFORMED CONSENT FORM
The information you provide in this form is secure on a HIPAA-compliant platform. If you do not have an email or would prefer to give information over the phone, please call the pharmacy at 270-885-5515.
How many doses of COVID-19 vaccine have you received?
0
1
2
3
Which vaccine did you receive?
*
Pfizer (age 12+)
Moderna
Janssen
Pfizer Pediatric (5-11)
You do not qualify for any additional doses at this time.
A booster dose is recommended for you if it has been at least two (2) months since your first dose. The CDC recommends receiving your booster dose from the same manufacturer as your primary dose(s), but you may opt to receive a dose from a different manufacturer.
Which vaccine would you prefer to receive?
*
Pfizer
Moderna
Janssen
We do not have that vaccine available at this time.
Date of First Dose
*
/
Month
/
Day
Year
Date
Date of Second Dose
*
/
Month
/
Day
Year
Date
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Please mark any of the following conditions that you meet:
*
I have been receiving active cancer treatment for tumors or cancers of the blood.
I have received an organ transplant and am taking medicine to suppress the immune system.
I have received a stem cell transplant within the last 2 years or am taking medicine to suppress the immune system.
I have moderate or severe primary immunodeficiency (such as DiGeorge syndrome, Wiskott-Aldrich syndrome).
I have advanced or untreated HIV infection.
I have active treatment with high-dose corticosteroids or other drugs that may suppress my immune response
None of the above apply.
Because you are considered moderately or severely immunocompromised, an additional third dose is recommended for you if it has been at least 28 days since your second dose.
A booster dose is recommended for those 18 or older if it has been at least six (6) months since your second dose. The CDC recommends receiving your booster dose from the same manufacturer as your primary dose(s), but you may opt to receive a dose from a different manufacturer.
Which booster vaccine would you prefer?
*
Pfizer
Moderna
Janssen
We do not have that vaccine available at this time.
By signing below and continuing, I attest that I meet one of more of the criteria listed above.
Signature of patient, power of attorney, or legal guardian
*
If not patient, relationship to patient
Printed name
*
Date
/
Month
/
Day
Year
Date
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Full Name (First MI Last)
*
Date of Birth
*
/
Month
/
Day
Year
Date
Age
*
Email
example@example.com
Phone
*
Address
*
Address
Street Address Line 2
City
State
Zip Code
Gender
*
Male
Female
Race
*
Please Select
African American
American Indian
Asian
Caucasian
Native Hawaiian/Other Pacific Islander
Other
Prefer not to answer
Ethnicity
*
Please Select
Hispanic/Latino
Non-Hispanic/Latino
Unknown
Prefer not to answer
Primary Care Doctor
Primary Care Doctor's City/State
Screening Questions
Please select the correct option below.
Do you feel sick today?
*
Yes
No
Don't Know or N/A
In the past two weeks, have you tested positive for COVID-19 or are you currently being monitored for COVID-19?
*
Yes
No
Don't Know or N/A
In the past 90 days, did you receive any medications, plasma or other treatment for COVID-19?
*
Yes
No
Don't Know or N/A
In the past two weeks, have you had a known exposure with anyone who tested positive for COVID-19?
*
Yes
No
Don't Know or N/A
Have you been diagnosed with Multisystem Inflammatory Syndrome (MIS-C or MIS-A) after a COVID-19 infection?
*
Yes
No
Don't Know or N/A
Have you had a new onset of fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, nausea, vomiting or diarrhea?
*
Yes
No
Don't Know or N/A
Do you have an allergy to any food, medication or vaccine?
*
Yes
No
Don't Know or N/A
Please specify allergy
*
Have you ever had a serious reaction or fainted after receiving any vaccination?
*
Yes
No
Don't Know or N/A
Do you carry an EpiPen?
*
Yes
No
Don't Know or N/A
Do you have a bleeding disorder or take a blood thinner?
*
Yes
No
Don't Know or N/A
Have you ever had a seizure, brain disorder, or Guillain-Barre Syndrome?
*
Yes
No
Don't Know or N/A
Do you have a weakened immune system (i.e., HIV infection, cancer) or take immunosuppressive drugs or therapies?
*
Yes
No
Don't Know or N/A
Do you have a history of myocarditis or pericarditis?
*
Yes
No
Don't Know or N/A
Do you have a history of heparin-induced thrombocytopenia (HIT)?
*
Yes
No
Don't Know or N/A
Have you received dermal fillers?
*
Yes
No
Don't Know or N/A
FOR WOMEN: Are you currently pregnant or breastfeeding?
*
Yes
No
Don't Know or N/A
Pfizer VIS
|
Moderna EUA
|
Janssen EUA
|
Flu Injection VIS
|
Flu Mist VIS
Other Vaccine Information Statements can be found by clicking here
.
Notice of Privacy Practices
Acknowledgements
I understand the benefits and risks of the vaccination(s) asdescribed in the Vaccine Information Sheet or Emergency Use Authorization, acopy of which I was provided with this Consent and Release. I have had a chanceto ask questions that were answered to my satisfaction. I request the vaccineto be given to me or to the person named above, a minor for whom I representthat I am authorized to sign this Consent and Release.
I have received a copy of the notice of Privacy Practices. Iunderstand the notice of Privacy Practices provides an explanation of the waysin which my health information may be used or disclosed by the pharmacy and ofmy rights with respect to my health information. I have been provided with the opportunityto discuss concerns I may have regarding the privacy of my health information.
Signature
*
Parent/Guardian Name
*
Relationship to patient
*
Insurance Information & Authorization
I hereby authorize the pharmacy and Dr. Laura Purdy to bill my insurance on my behalf for the COVID-19 vaccine administration fee and/or a different vaccine and receive payment.
Insurer
Member #
BIN #
Rx Group
PCN #
Social Security #
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.
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