VaxOn Consent Form (JIAR)

Section I. Personal Information

Patient's Name:*

First NameMlLast Name

Date of Birth:*

Phone Number:*

Email:*

Gender:*

MaleFemale

Address:*

Street Address Line 2

Primary Care Doctor:

Adult or Pediatric Vaccine?*

Adult Vaccine.Pediatric COVID Vaccine (5-11)

Which Vaccine would you like to get?*

Pfizer COVID Vaccine/Booster.Moderna COVID Vaccine/Booster.J&J COVID Vaccine/Booster.

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

First DoseSecond DoseThird Dose (Boooster)

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

First DoseSecond Dose

When did you receive your first dose?*

Date

When did you receive your second dose?*

Date

When was your child's first dose?*

Date

Appointment

Section II. Immunization Questionnaire

Please answer all the following Questions*

	Yes	No
COVID-19 Screening Questions: In the past two weeks, have you tested positive for COVID-19 or are you currently being monitored for COVID-19?
In the past two weeks, have you had a known exposure with anyone who tested positive for COVID-19?
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?
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.)? ...................................
Have you received any vaccinations in the past 14 days?
Have you received COVID-19 monoclonal antibodies or convalescent plasma in the last 90 days?
Have you ever had a serious reaction or fainted after receiving any vaccination?
Have you ever had a seizure, brain disorder, or Guillain-Barre Syndrome?
Do you have any chronic health condition such as Cancer, Chronic Kidney Disease, Immunocompromised, Chronic Lung Disease, Obesity, Sickle Cell Disease, Diabetes, Heart Disease, Other? .................................................
For women: Are you pregnant or are you planning on becoming pregnant during the next month?

Do you have Health Insurance?*

YesNo

What type of Insurance do you have?*

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

Please take or upload pictures of front & back of insurance card for billing purposes*

Upload Insurance Card

In order to have your vaccine administration fee paid for by the United States Health Resources & Services Administration's (HRSA) COVID-19 Program for uninsured patients, please provide your Identification Number (State ID or a Driver's License) and upload your photo ID:

Identification Number (State ID or Driver's License)*

Please take or upload pictures of front & back of your State ID or Driver's License for verification and billing purposes*

Upload your photo ID

Section V. Consent

I certify that I am: (i) The patient and at least 18 years of age; (ii) The parent or legal guardian of the minor patient; or (iii) The legal guardian of the patient. Further, I hereby give my consent to the health care provider of Vaxon, LLC to administer the vaccine(S) I have requested above. I understand that it is not possible to predict all possible side effects or complications as associated with receiving the vaccine(s). I understand the risks and benefits associated with the above vaccine(s) and have read, and/or had explained to me the Vaccine Information Statements (VIS)/ Emergency Use Authorization sheet (EUA) on the vaccine(s) I have elected to receive. I also acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction. Further, I acknowledge that I have been advised to remain near the vaccination location for approximately 15 minutes after administration for observation by the administering health care provider. On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless Vaxon, LLC its staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of vaccine(s) listed above. I authorize Vaxon, LLC to release medical or other information to my health care professionals, Medicare, Medicaid or other third party payor necessary to effectuate care or payment and request that payment of authorized benefits be made on my behalf to Vaxon, LLC with respect to the vaccine(s) listed above. I also acknowledge that 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. I consent that I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA), a copy of which I was provided with this Consent and Release.

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

Date

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.

Vaccine Consent Form