COVID Vaccine Consent Form

Vaccine Consent Form Location: 7 Willow St Lynn MA 01901

* Please fill out the required details below
- Please fill out the form below to make an appointment for you COVID-19 and other vaccines.
- We have all vaccines in stock.
  - COVID-19 (Comirnaty by Pfizer) *** limited supply ***
  - COVID-19 (Spikevax by Moderna)
  - RSV (Arexvy by GSK)
  - Influenza or Flu (Regular and High Dose for 65+)
  - Shingles (Shingrix by GSK)
  - Pneumonia (Pneumovax 23 and Pravnar 20)
  - Tetanus, Diphtheria, and Pertussis (BOOSTRIX by GSK)
- What to bring to the appointment
  - Your ID (not required but helpful)
  - RX insurance card (not required but helpful)
  - Medicare A/B card (if you have one)
  - Wear clothing that will allow access to your upper arm.
- Fields with a Red Star* are required.
- If you have any questions or are unable to fill out the form then, please call us at (781) 599-5900.
Section I. Personal Information
Patient's Full Name:*

First NameMlLast Name
Name

First NameLast Name
Date of Birth:*

MonthDayYear
Phone Number:*
Have you had a prescription filled at Flag Pharmacy in the past 90 days?*

YesNo
Email*
example@example.com
Sex at Birth:*

MaleFemale
Ethnicity:*

Hispanic or LatinoNon Hispanic/LatinoUnknownPrefer not to answer
Race:*

African AmericanAmerican IndianAsianCaucasianNative Hawaiian/Other Pacific IslanderPrefer not to answerOther
Address:*

Street Address Line 2
Primary Care Doctor:
Doctor City/State:
Which vaccine would you like to get at your appointment?*

COVID-19Flu Regular Vaccine (5 years and older )Flu High Dose Vaccine (65+ only)Pneumonia VaccineRSV (Arexvy by GSK)Shingles Vaccine (Shingrix)Tetanus Vaccine (BOOSTRIX)Other
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 DoseSecond DoseBooster Dose (third and up)
When did you receive your last dose?

MonthDayYear
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?

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 (1)*
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.
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.

Browse Files

Cancelof
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 planI will pay for all vaccines at the pharmacy.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 (last 4 number only).I do not have a Social Security number.
Last four numbers of your Social Security Number
Should be Empty:

Vaccine Consent Form Location: 7 Willow St Lynn MA 01901