MODERNA &PFIZER COVID VACCINE CLINIC PRIMECARE PHARMACY COVID VACCINE APPOINTMENT & CONSENT FORM

1
Have you ever received a dose of COVID-19 Vaccine?
YESNO
2
Are you a front-line healthcare worker or resident/staff of a long-term care facility or home healthcare staff or First responders with Direct public exposure (Police, Fire, EMS, rescue squad, corrections officers, jailers or individuals > 18 years of age who cannot live independently due to serious chronic medical condition or intellectual or developmental disability ?* This field is required.This group is considered Phase 1A1
YESNO
3
Moderna or Pfizer-BioNTech COVID-19 BIVALENT Booster Vaccine Eligibility
4
Moderna or Pfizer-BioNTech COVID-19 BIVALENT Booster Vaccine Eligibility Chart
5
Are you an out-patient health care workers with direct patient exposure - Primary care providers and staff, pharmacist & staff, patient transport, outpatient therapists, Urgent Care providers & staff, oral health providers, behavioral health providers, outpatient laboratory staff working with COVID specimen or funeral/mortuary workers with direct decedent contact ?* This field is required.This group is considered Phase 1A2
YESNO
6
Are you a K-12 Teacher/Educator, Child Care teachers and Staff or first responders including first responder administrative personnel, dispatchers, communications personnel, other emergency communications personnel not included in Phase 1a1?* This field is required.This group is considered Phase 1A2
YESNO
7
Is Vaccine Recipient 18 years and older ?* This field is required.MINIMUM AGE LIMIT FOR MODERNA & JANSSEN J&J VACCINE IS 18 YEARS.
YESNO
8
Are you 16 years of age and older with at least any of chronic medical condition listed below? Check all that apply* This field is required.This group is considered Phase 1C . You must be 18 years of age to get MODERNA
Chronic kidney disease
COPD (chronic obstructive pulmonary disease) / Pulmonary Fibrosis/ Cystic Fibrosis/ Moderate-Severe Asthma
Cerebro-Vascular Disease or History of Stroke
Obesity and severe obesity (BMI >30 OR Body Mass Index of 30 kg/m2 or higher)
Heart Failure/Coronary Artery Disease/Cardiomyopathy/Hypertension
Solid organ transplantation
Liver disease, including hepatitis
Sickle cell disease / Thalassemia
Diabetes mellitus requiring medication
Dementia
Individuals age > 16 years who are immunocompromised (such as individuals receiving chemotherapy, requiring daily oral steroids or other immunosuppressant medicines, people living with HIV/AIDS or other diagnosed high-risk Immunodeficiency)
Household resident or caregiver of medically fragile children < 16 years who are technologically-dependent individuals, immunocompromised individuals, individuals with diabetes requiring medication, individuals with complex congenital or life-threatening cardiac conditions requiring ongoing medical management, individuals qualifying for a Katie Beckett waiver).
Technologically-dependent (such as individuals who are ventilator-dependent, oxygen-dependent, with tracheostomy, chronically wheel chair-bound, require tube feedings, parenteral nutrition, or dialysis)
Cancer
Women ages 16 years and older who are pregnant and their permanent household residents >16yo.
High-risk, progressive neuromuscular disorders (such as muscular dystrophy, ALS, multiple sclerosis)
Down Syndrome
NONE OF THE ABOVE / NO CHRONIC MEDICAL ISSUE
9
Are you employed in the following Critical Infrastructure Industries Social Services (DCS) (includes child welfare agency personnel with direct public exposure), Commercial agriculture, Commercial food production, Corrections staff not included in 1a1 (includes administrative staff, those without regular public/inmate contact) or* This field is required.This group is considered Phase 2A
YESNO
10
Are you employed in the following that are critical Infrastructure Industries to the continuation of operations for certain sectors such as safety, mechanical, and engineering personnel for Transportation (including postal and package delivery) freight, railroad, maritime cargo, and commercial or cargo service airports; mechanical, and engineering personnel for courier and parcel delivery service; public infrastructure workers responsible for operation or safety of dams, locks, bridges, and roads and for solid waste collection and processing; telecommunications industry technicians and engineers involved in installation, operations and maintenance functions; and safety, production, distribution, mechanical and engineering personnel for utilities and energy sector operations, Transportation (including postal and package delivery, freight railroad, maritime cargo, commercial or cargo service airports) , Public infrastructure (includes dams, roads, locks, and bridge maintenance and engineering, solid waste collection, and processing), Telecommunications (includes those providing direct services)* This field is required.This group is considered Phase 2A
YESNO
11
Attestation and Certification :- I, hereby, attest, affirm and certify that all the information and answers to questions herein are complete, true and correct.* This field is required.
12
EMERGENCY USE AUTHORIZATION* This field is required.
13
Terms and Conditions* This field is required.I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet, a copy of which I was provided with this Consent Form physically or electronically. 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 fully release and discharge PRIMECARE PHARMACY, its affiliates, their officers, directors and employees from any liability for illness, injury, loss or damage which may result there from. I understand that at this time, the COVID-19 vaccine requires 2 doses given 21-28 days apart depending on the manufacturer. If this is my first dose of the COVID-19 vaccine, I intend to receive a second dose of the same vaccine in accordance with the timeframe specified in the Fact Sheet to complete the vaccination series. 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. If insured, please bring in your prescription and medical insurance cards for your vaccine appointment. If uninsured, you must 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 benefit plan.
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Appointment* This field is required.
15
Vaccine Recipient Name* This field is required.
First Name
Middle Name
Last Name
16
Vaccine Recipient Physical Address* This field is required.
Street Address
Street Address Line 2
City
State Initials
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
17
Date of Birth* This field is required.Minimum age to get Moderna Vaccine is 18 years. (Type and Enter the date first in mm-dd-yyyy format and then click on the calendar icon on right side and then select date again. If this fails try signing from a Desktop Computer or call us)
mm-dd-yyyy
Month
Day
Year
18
Gender at birth* This field is required.
Please Select
Please Select
Male
Female
19
Race* This field is required.
Please Select
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
20
Ethnicity* This field is required.
Please Select
Please Select
Hispanic or Latino
Not Hispanic or Latino
Unknown
21
Vaccine Recipient Phone Number* This field is required.
22
Email Address * This field is required.
example@example.com
23
Mother's Maiden Name* This field is required.
Required for proper vaccine documentation
24
Primary Care Provider Name* This field is required.
25
Emergency Contact Name* This field is required.
26
Relationship to Emergency Contact* This field is required.eg:- SPOUSE / BROTHER / SISTER / FATHER / MOTHER / FRIEND / COUSIN
27
Emergency Contact Phone Number* This field is required.
Please enter a valid phone number.
28
Which Insurance do you have ? If no insurance click "No Insurance"* This field is required.If insured, please bring in your PRESCRIPTION and MEDICAL INSURANCE Cards especially MEDICARE PART B Card (red-white & blue card) if you have Medicare for your vaccine appointment. I authorize the pharmacy to bill my insurance on my behalf for the vaccine administration charges understanding I will not incur any costs. Uninsured meaning if you not have any insurance, including but not limited to, Medicare, Medicaid, or any other private or government-funded benefit plan
Commercial
Medicare
No Insurance
29
What is your Insurance ID Number, if Medicare, please input the number from the Red, White & Blue Card* This field is required.
30
COVID-19 Vaccine Screen Questions* This field is required.Allergic Reaction Defined: This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.
Yes
No
1. Are you feeling sick today?
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2. Have you had a new onset of fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle/body aches, new loss of taste or smell, sore throat, nausea, vomiting, or diarrhea?
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3. Have you ever received a dose of COVID-19 Vaccine?
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4a. Have you ever had an allergic reaction to a component of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures or to Polysorbate ?
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4b. Have you ever had an allergic reaction to medications, foods, or any vaccines (eggs, gelatin, thimerosal, neomycin, gentamicin, latex, aluminum, preservatives, baker's yeast, etc?
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4c. Have you ever had an allergic reaction to a previous dose of COVID-19 Vaccine?
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5. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?
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6. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a component of COVID-19 vaccine, polysorbate, or any vaccine or injectable medication?
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7.  Have you received any vaccine in the last 14 days?
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8.  Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19?
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9. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?[note: monoclonal antibodies does not include antibiotics that you would be prescribed and filled at a pharmacy]
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10.  Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
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11. Do you have a bleeding disorder or are you taking a blood thinner?
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12. Are you pregnant or breastfeeding?
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1. Are you feeling sick today?
2. Have you had a new onset of fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle/body aches, new loss of taste or smell, sore throat, nausea, vomiting, or diarrhea?
3. Have you ever received a dose of COVID-19 Vaccine?
4a. Have you ever had an allergic reaction to a component of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures or to Polysorbate ?
4b. Have you ever had an allergic reaction to medications, foods, or any vaccines (eggs, gelatin, thimerosal, neomycin, gentamicin, latex, aluminum, preservatives, baker's yeast, etc?
4c. Have you ever had an allergic reaction to a previous dose of COVID-19 Vaccine?
5. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?
6. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a component of COVID-19 vaccine, polysorbate, or any vaccine or injectable medication?
7.  Have you received any vaccine in the last 14 days?
8.  Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19?
9. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?[note: monoclonal antibodies does not include antibiotics that you would be prescribed and filled at a pharmacy]
10.  Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
11. Do you have a bleeding disorder or are you taking a blood thinner?
12. Are you pregnant or breastfeeding?
Yes
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No
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Yes
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No
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Yes
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No
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Yes
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No
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Yes
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No
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Yes
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No
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Yes
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No
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Yes
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Yes
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Yes
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Yes
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Yes
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No
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Yes
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No
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Yes
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No
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Have you ever had an allergic reaction to a component of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures or to Polysorbate ? * This field is required.
YESNO
32
Have you ever had an allergic reaction to medications, foods, or any vaccines (eggs, gelatin, thimerosal, neomycin, gentamicin, latex, aluminum, preservatives, baker's yeast, etc? * This field is required.
YESNO
33
List ALL the medications and/or any previously mentioned products that you are allergic to ?* This field is required.
34
Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?* This field is required.
YESNO
35
List ALL the Injectables and/or any previously mentioned products that you are allergic to ?* This field is required.
36
Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a component of COVID-19 vaccine, polysorbate, or any vaccine or injectable medication? * This field is required.
YESNO
37
Have you ever received a dose of COVID-19 Vaccine ? * This field is required.
YESNO
38
COVID-19 Vaccine Manufacturer for the first dose received
Moderna
Pfizer
Janssen (J&J)
Required if you selected "Yes" to #2
39
Date of Second dose
Required if you selected "Yes" to #2
Month
Day
Year
40
Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19 ? * This field is required.
YESNO
41
What was the date of the positive test for COVID-19 or has a health care provider ever told you that you had COVID-19 ? * This field is required.
Required if you selected "Yes" to #2
Month
Day
Year
42
Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?[note: monoclonal antibodies does not include antibiotics that would be prescribed to you and filled at a pharmacy] ? * This field is required.
YESNO
43
If have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19, What was the date that you received this therapy ?[note: monoclonal antibodies does not include antibiotics that would be prescribed to you and filled at a pharmacy] ? * This field is required.
Required if you selected "Yes" to #2
Month
Day
Year
44
Consent (check each box below after reading and prior to signing the form)* This field is required.
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 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 fully release and discharge PrimeCare Pharmacy, its affiliates, their officers, directors and employees from any liability for illness, injury, loss or damage which may result there from.
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I understand that at this time, the COVID-19 vaccine requires 2 doses given 21-28 days apart depending on the manufacturer. If this is my second dose, I will bring my vaccine card with me to be completed.
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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.
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I understand that I will be receiving the vaccination at no cost to me.
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I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet (the 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 fully release and discharge PrimeCare Pharmacy, its affiliates, their officers, directors and employees from any liability for illness, injury, loss or damage which may result there from.
I understand that at this time, the COVID-19 vaccine requires 2 doses given 21-28 days apart depending on the manufacturer. If this is my second dose, I will bring my vaccine card with me to be completed.
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
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Check each box
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Check each box
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Check each box
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The vaccine is available to anyone no matter if insured or uninsured. Please check only one of the following.* This field is required.
Check one
If INSURED, check this box attesting to bringing in your prescription and medical insurance cards for your vaccine appointment. By selecting this, you are also authorizing the pharmacy to bill your insurance on your behalf for the immunization – understanding you will not incur any costs.
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If UNINSURED, you must check this box to attest that the 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 benefit plan.
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If INSURED, check this box attesting to bringing in your prescription and medical insurance cards for your vaccine appointment. By selecting this, you are also authorizing the pharmacy to bill your insurance on your behalf for the immunization – understanding you will not incur any costs.
If UNINSURED, you must check this box to attest that the 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 benefit plan.
Check one
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Check one
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For uninsured patients, please select at least TWO of the following that you will bring with you to your appointment.This is needed in order to have your vaccine administration fee paid for by the United States Health Resources & Services Administration's COVID-19 Program.
Social Security Number
State identification number and state of issuance
Driver's license number and state of issuance
47
Attestation and Certification * This field is required. I, hereby, attest, affirm and certify that all the information and answers to questions herein are complete, true and correct.
Clear
48
Emergency Use Authorization * This field is required.I understand the benefits and risks of the COVID-19 vaccine as described in the EMERGENCY USE AUTHORIZATION (EUA) Fact Sheet, a copy of which I was provided electronically or physically. 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 fully release and discharge PrimeCare Pharmacy, its affiliates, their officers, directors and employees from any liability for illness, injury, loss or damage which may result there from.
Clear
49
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):* This field is required.
Clear
50
Date Signed* This field is required.PLEASE NOTE :- IF YOU ARE GETTING "GATEWAY ERROR MESSAGE" AFTER SUBMITTING, PLEASE CALL US BEFORE RESUBMITTING (YOUR SUBMISSION MIGHT BE STILL SUCCESSFUL). If you cannot call immediately, call us at the earliest possible time, you WILL NOT lose the place in appointment.
Date
Month
Day
Year
51
YOU ARE NOT ELIGLIBLE TO GET THE VACCINE

Currently we are giving MODERNA VACCINE and the minimum age to recieve Moderna Vaccination is 18 years and above.
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