• Influenza & COVID-19 Vaccine Scheduling and Consent Form

    Please read below carefully and fill out the form to the best of your knowledge. If you have any questions about the influenza or COVID-19 vaccines, please reach out to a staff member at Burry's Pharmacy, (352)787-3787.
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  • Patient Demographic Information

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  • 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

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  • Patient Prescription Insurance

  • Emergency Contact Information

  • 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 ) 

     

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