Burry's Pharmacy Influenza & COVID-19 Vaccines

Appointment*

Patient Demographic Information
Name*

FirstNameLastName
Date of Birth*

MonthDayYear
Date
Patient Address*

AddressOne

AddressTwo

CityStateCode

Zip
Is the patient LESS than 18 years old, and/or UNABLE to provide medical consent for themselves?*

YesNo
Patient Gender: (M: Male and F: Female)*

MF
Which arm would you like to receive your shot? (Can be changed at appointment)*

Left ArmRight Arm
Patient Primary Phone Number: (Please double check for accuracy)*
Please enter a valid phone number.
Email*
example@example.com (We will send a confirmation and reminder email here)
Race*
Ethnicity *
County of Residence (Ex: Lake, Sumter, Marion, etc.)*
Patient's Mother's Maiden Name: (Needed for reporting to Department of Health)*
I am a Florida resident with a valid Florida driver license or a copy of a valid Florida identification card that I will bring with me on the day of my appointment*

YesNo
State Surgeon General Scott Rivkees issued a Public Health Advisory on January 21 prioritizing vaccines for residents of the State of Florida or individuals in Florida for the purpose of providing health care services involving direct contact with patients.

To prove residency an adult resident must provide a copy of his or her valid Florida driver license or a copy of a valid Florida identification card.

Seasonal residents may provide a copy of two of the following the show proof of residential address:
1. A deed, mortgage, monthly mortgage statement, mortgage payment booklet or residential rental or lease agreement.
2. One proof of residential address from the season resident’s parent, step-parent or legal guardian or other person with whom the seasonal resident resides and a statement from the person with whom the seasonal resident resides stating that the seasonal resident does reside with him or her.
3. A utility hookup or work order dated within 60 days before registration.
4. A utility bill, not more than 2 months old.
5. Mail from a financial institution, including checking, savings, or investment account statements, not more than 2 months old.
6. Mail from a federal, state, county, or municipal government agency, not more than 2 months old.
Patient Medical History

	Yes	No	Don't know
Have you ever experienced a serious reaction after getting a vaccine?
Do you have allergies to medication, food, a vaccine component, or latex?
Do you have cancer, leukemia, HIV/AIDS, or other immune system problems?
In the past 3 months have you taken medications that affect your immune system such as prednisone, other steroids, anticancer drugs, radiation treatments, or drugs for rheumatoid arthritis, Crohn's disease, and psoriasis?
During the past year have you received a transfusion of blood, blood products, immune (gamma) globulin, or an antiviral drug?
For women: Are you currently lactating or breastfeeding?
Have you received any vaccinations in the past 4 weeks?

If you answered "yes" to any of the questions above, please explain here:
Patient Prescription Insurance
Do you have health insurance?*

Yes, I DO have health insuranceNo, I DO NOT have health insurance (uninsured)
If you answered YES to the question above, please select which type of insurance you have: (Select ALL that apply):*

I am an existing Burry's Pharmacy patient and my insurance is up to date in the systemMedicare Part A/B (Red, White, & Blue Card for patients over the age 65)Prescription Insurance (Coverage for medications at a pharmacy)
Medicare Part B ID (If 65 years or older or have Part B coverage)*
Red White & Blue Card. If you do not have your card please enter your Social Security Number. Please note that all COVID vaccines are billed to Medicare directly and cannot be billed to HMO/PPO/Advantage Plans.
Rx BIN*
This information is found on your PRESCRIPTION insurance card
Rx PCN*
This information is found on your PRESCRIPTION insurance card
Rx GROUP ID*
This information is found on your PRESCRIPTION insurance card
Member ID*
This information is found on your PRESCRIPTION insurance card
Emergency Contact Information
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Emergency Contact Relationship*
COVID-19 Vaccine Acknowledgement
The COVID-19 vaccine will reduce the risk of suffering from the new type of Coronavirus disease as known as COVID-19.

Please be aware that the vaccine is not completely effective like all other medicines. It can take a few weeks for your body to build up protection from the vaccine. There is always a chance of getting infected by Coronavirus even with the vaccine; however, the vaccine lessens the severity of any infection. A dose will reduce the chance of being seriously ill and reduce the risk of death due to Coronavirus.

This vaccine does not give you COVID-19 infection, but you still need to follow the health instructions in your workplace and in public areas, such as wearing a mask and keeping a distance from others.

The vaccine has some side effects as the other vaccines/medicines, but not everyone gets them.

The most likely side effects that you may experience from the vaccine:
- Fever
- Pain at the injection site
- Redness and hardness of the skin at the injection site
- Headache
- Muscle aches or pain
- Joint aches or pain
- Fatigue (tiredness)
- Nausea/vomiting
- Chills
- Underarm gland swelling on the side of vaccination
By signing this form I hereby accept that:
- I have read and understood the acknowledgment letter provided above.
- I declare that the information I have provided above is correct.
- I am giving my full consent to get the COVID-19 vaccine of my own will.
- This appointment CANNOT be rescheudled.
- I will show up ON TIME for my appointment.
- If I miss my appointment for any reason I will LOSE MY RESERVED COVID-19 VACCINE and will be required to wait until new apointments are available.
- I have been provided with the Vaccine Recipient Fact Sheet (Pfizer: https://www.fda.gov/media/144414/download, Moderna: https://www.fda.gov/media/144638/download, Johnson & Johnson: https://www.fda.gov/media/146305/download)
- I have been provided with information about the CDC's V-safe After Vaccination Health Checker (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/vsafe.html )
Date of Form Completion*

MonthDayYear
Date
Signature*

Clear
Should be Empty:

Influenza & COVID-19 Vaccine Scheduling and Consent Form

Patient Demographic Information

Patient Medical History

Patient Prescription Insurance

Emergency Contact Information

COVID-19 Vaccine Acknowledgement