COVID Vaccine Consent Form

COVID Vaccine Consent Form - Wells Hometown Drug

* Please fill out the required details below
If you have remaining questions, please call us at 641-664-3100
Section I. Vaccine will be administered at Wells Hometown Drug
Section II. Personal Information
Student's Full Name:*

First NameMlLast Name
Date of Birth:*

MonthDayYear
Age:
Phone Number:*
Gender:*

MaleFemale
Address:

Street Address Line 2
Section III. Questionnaire for Immunization
Date of First Vaccination

MonthDayYear
Date
Date of Second Vaccination if Moderna or Pfizer

MonthDayYear
Date
Section IV. Signature

I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) available at wellshometowndrug.com. 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

Clear
Parent/Legal Guardian if Applicable
Print Name
Insurance Authorization and Information

I authorize the pharmacy to bill my insurance on my behalf for the immunization
If we do not have your insurance information please complete
If uninsured please enter your Social Security Number or Driver's License Number
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. You will receive a thank you page which means your submission was a success.
Email-For Confirmation
example@example.com
Should be Empty:

COVID Vaccine Consent Form - Wells Hometown Drug