COVID CONSENT w additional r7

Name *

PATIENT’S FIRST NAME PATIENT’S LAST NAME
birth date *

Month Day Year
Age
Address *

Address

Street Address Line 2

(street, city, state, zip)
Cell Phone Number *
Email *
example@example.com
Gender *
Race
Ethnicity
Drug Insurance ID Number
Medicare B HICN
red white blue paper card
Please attach a picture of your drug insurance card *red/white/blue paper Medicare card if you have Medicare part B
Primary Care Doctor
Are you feeling sick today? *

Yes No
Have you ever received a dose of COVID-19 Vaccine? *

Yes No
Which Vaccine(s) have you had

Pfizer Moderna J&J Janssen
Please provide the date(s) of previously received vaccines
Have you ever had a severe allergic reaction (e.g. anaphylaxis) caused by any of the following *

Polyethylene glycol (PEG) Polysorbate Previous COVID-19 vaccine Other injection No, none of the above
calculation
monitor time
Check all that apply to you

Am a female between ages 18 & 49 years old Am a male between ages 12 & 29 years old Have a history of myocarditis or pericarditis Had a severe allergic reaction to something other than a vaccine or injectable therapy such as food, pet, venom, environmental or oral medication allergies Had COVID-19 and was treated with monoclonal antibodies or convalescent serum Diagnosed with Multisystem Inflammatory Syndrome (MIS-Cor MIS-A) after a COVID-19 infection Have a weakened immune system (i.e., HIV infection, cancer) or take immunosuppressive drugs or therapies Have a bleeding disorder Take a blood thinner Have a history of heparin-induced thrombocytopenia (HIT) Am currently pregnant or breastfeeding Have received dermal fillers History of Guillain-Barré Syndrome (GBS)
Consent (check each box below after reading carefully) *

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. 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, whom I represent that I am authorized to sign this Consent Form. I understand that mRNA vaccines require a series of 2 doses (& an additional dose 28 days later for immunocompromised patients). A booster dose may be given at least 5 months after an mRNAprimary vaccine series, or 2 months after Janssen. Age 50+ may get a 2nd booster 4months later. If this is a subsequent dose, I will bring my vaccine card with me to be updated. I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my I understand that I will be receiving the vaccination at no cost to me.
Insurance *

I am insured. I will bring my prescription and/or Medicare part B card to my appointment. I authorize the pharmacy to bill my insurance on my behalf for the immunization, understanding that I will not incur any costs I do not have any insurance, including but not limited to, Medicare, Medicaid, or any other private or government-funded benefit plan.
Please provide the identification type and ID number to be used for billing the HRSA uninsured program. Bring this card to your appointment
Drivers license - S000000 / SS# 000-00-0000
Links to the CDC Emergency Use Authorization (EUA) or Vaccine Information Statement (VIS)

Moderna

Pfizer

Janssen
“I have read the adverse reactions associated with the administration of vaccines. I understand that some products or indications have not been approved or licensed by FDA, but has been authorized for emergency use by FDA, under an EUA to prevent Coronavirus Disease 2019 (COVID-19) for use in individuals 12 or 18 years of age and older. I believe the benefits outweigh the risks and I voluntarily assume full responsibility for any reactions that may result from the patient’s receipt of the immunization(s) Patient medical record may be shared with my physician or other healthcare and will be recorded in the Massachusetts Immunization Information System. I am requesting that the immunization(s) be given to me or my Ward. I, for myself and on behalf of my Ward, and each of our respective heirs, executors, personal representatives and assigns, hereby release the pharmacy, and its affiliates, subsidiaries, prescriber, divisions, directors, contractors, agents and employees (collectively “Released Parties”), from any and all claims arising out of, in connection with or in any way related to my receipt and the receipt by my Ward of this or these immunization(s Neither the pharmacy nor any of the Released Parties shall, at any time or to any extent whatsoever, be liable, responsible or any way accountable for any loss, injury, death or damage suffered or sustained by any person at any time in connection with or as a result of this vaccine program or the administration of the vaccines described above. The pharmacy will use and disclose your personal and health information or the personal and health information of your Ward, to treat you or your Ward, to receive payment of the care we provide, and for other health care operations. Healthcare operations generally include those activities we perform to improve the quality of care. I acknowledge that I have been offered a Notice of Privacy Practices.” “I request that payment of authorized Medicare benefits be made to me or on my behalf to Whole Health Pharmacy for any services furnished me. I authorize any holder of medical information about me to release to the Centers for Medicare & Medicaid Services and its agents any information needed to determine these benefits payable for related services.” “I understand that the novel Coronavirus (COVID-19) has been declared a global pandemic by the World Health Organization (WHO I further understand that COVID-19 is extremely contagious and may be contracted from various sources. I understand COVID- 19 has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. I understand my treatment may create circumstances, such as person-to-person contact, in which COVID-19 can be transmitted. I understand that I am opting for an elective treatment that may not be urgent or medically necessary, and that I have the option to defer my treatment to a later date. However, while I understand the potential risks associated with receiving treatment during the COVID-19 pandemic, I agree to proceed with my desired treatment at this time. I understand due to the frequency of appointments with patients, the attributes of the virus, and the characteristics of procedures, I may have an elevated risk of contracting COVID-19 simply by being at the treatment location. I confirm I am not experiencing any of the following symptoms of COVID-19: *Fever *Dry Cough *Sore Throat *Shortness of Breath *Runny Nose *Loss of Taste or Smell. I am informed that you and your staff have implemented preventative measures intended to reduce the spread of COVID-19. However, given the nature of the virus, I understand there may be an inherent risk of becoming infected with COVID-19 by proceeding with this treatment. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective treatment and give my express permission to you and the staff at your offices to proceed with providing care. I have been offered a copy of this consent form. I KNOWINGLY AND WILLINGLY CONSENT TO THE TREATMENT WITH THE FULL UNDERSTANDING AND DISCLOSURE OF THE RISKS ASSOCIATED WITH RECEIVING CARE DURING THE COVID-19 PANDEMIC
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian): *

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Date

Month Day Year
Date
administer date

Month Day Year
Date
Lot Number
Vaccine Manufacturer
Please select the vaccine you prefer to get *
Vaccine selection
Clinic Location
Appointment *
appointment selection
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