In_House_Booster

COVID-19 Vaccine Consent

Please have your pharmacy insurance card ready when completing. If you are having difficulty completing this form, feel free to call us at 804-733-7711.
*Pharmacy Use Only* Temperature: __________ COVID Symptoms: Y or N
Patient Name*

Last NameMiddle NameFirst Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date

MonthDayYear
Date
Date of Birth*

MonthDayYear
Date
Gender at birth*
Age*
Must be 18 Years or Older at this time.
Ethnicity*
Patient Phone Number*
Driver's License Number*
What dose are you looking to receive?*

First DoseSecond DoseBooster
I have received a Pfizer or Moderna 2nd dose, OR Johnson & Johnson primary dose, OR, booster at minimum 2 MONTHS AGO*

Yes, Moderna or PfizerYes, Johnson & JohnsonNo
You may not yet be eligible to receive the booster.

Contact Walnut Hill Pharmacy at 804-733-7711 to determine your eligibility.
Date of last vaccination MM/DD/YYYY*

I request the following first/second dose:*

PfizerModerna
I request the following booster dose*

PfizerModerna
Would you like to receive a flu shot during this appointment as well?

YesNo
Schedule Your Appointment*
Schedule Your Appointment*
Payment

Vaccines may be billed to your pharmacy benefits. Please contact your plan directly if you have questions regarding insurance coverage of vaccines.
Choose a payment method*

Medicare Part B (Red, White and Blue card)Commercial Insurance/MedicaidNo Insurance

If you are able, lease take or upload pictures of the front & back of insurance card for billing purposes. *NOTE* If you are a current patient of ours, we will have your insurance information on file, and this section is not necessary. Please bring this information with you to your appointment.

Cancelof
Insurance Card Information

Please input each of the following for your insurance card. *NOTE* If you are a current patient of ours, we will have your insurance information on file, and this section is not necessary. Please bring this information with you to your appointment.
Bin number
PCN
Rx Group
Identification Number
Medicare ID Number (Red, White, and Blue card)
Please take or upload pictures of the front & back of insurance card for billing purposes. *NOTE* If you are a current patient of ours, we will have your insurance information on file, and this section is not necessary. Please bring this information with you to your appointment.

Cancelof

Consent to Vaccination

I have read, or have had read to me, the written information regarding the vaccine(s) being administered. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s) being administered and have received a copy of a current Vaccine Information Sheet. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Walnut Hill Pharmacy, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s). I certify that I am at least 18 years old and hereby give my consent to the pharmacists of this Pharmacy to administer the vaccine(s). If under 18 years old signature by parent or guardian is required. I agree to wait near the vaccination location for approximately 15 minutes for observation by the pharmacist.
The products and/or services provided to you by Walnut Hill Pharmacy are subject to the supplier standards contained in the Federal Regulations shown at 42 Code Of Federal Regulations Section 424.57(c ). These standards concern business professional and operational matters(e.g. honoring warranties and hours of operation). The full text of these standards can be obtained at http://ccfr.gpoacccss.gov. Upon request we will furnish you a written copy of the standards.
By signing this form I consent that I have received the HIPAA Privacy Practices and completed this form completely and to the best ofmy knowledge.

Pfizer Fact Sheet
Moderna Fact Sheet
Form completed by*

First NameLast Name
Signature of Person Receiving the Immunization (or Parent/Guardian of person < 18 years old)*

Clear
FOR PHARMACY USE ONLY

Vaccine/Manufacturer: COVID-19/Pfizer or Moderna Route and Dose: IM 0.5ML or 0.3ML or 0.25ML

Date Given _______ Site Given: LD RD RPH Initials _______
- Lot/Expiration _______ Comments _______________ Fact Sheet Date: 09/23
Should be Empty:

	Yes	No
1. Are you sick today?
2. Have you ever received a dose of COVID-19 vaccine?
3. Have you received any vaccine in the past 14 days.
4. For women: are you pregnant or is there a chance you could become pregnant during the next month?
5. Do you take cortisone, prednisone, other steroids, or anticancer drugs, or have had any x-ray treatments?
6. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? Vaccine can not be given within (90 days) of treatment.
7. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
8. Do you have a bleeding disorder or take a blood thinner?

	Check each box
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet (the Pfizer Fact Sheet or Moderna Fact Sheet is available after clicking submit), a copy of which I was provided with this Consent Form. 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 Form.
I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.
I understand that I will be receiving the vaccination at no cost to me.

	Check each box
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet (the Pfizer Fact Sheet or Moderna Fact Sheet is available after clicking submit), a copy of which I was provided with this Consent Form. 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 Form.
I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.
I understand that at this time, the Moderna COVID-19 vaccine requires 2 doses given 28 days apart, and the Pfizer COVID-19 vaccine requires 2 doses given 21 days apart. If this is my second dose, I will bring my vaccine card with me to be completed.
I understand that I will be receiving the vaccination at no cost to me.

COVID-19 Vaccine Consent

You may not yet be eligible to receive the booster.

Payment

Insurance Card Information

Consent to Vaccination