• COVID-19 In-Store Vaccination Scheduler and Consent Form

  • In-store vaccinations by 5 Minute Pharmacy is limited to adults ages 18 years and older.
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  • COVID-19 Vaccination Consent and Release

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  • Considerations from the CDC Administration of a COVID-19 vaccine with other vaccines.

    COVID-19 vaccines may be administered without regard to timing of other vaccines, including simutaneous administration History of a previous or current COVID-19 infection You may receive a COVID-19 vaccine if you have had a previous COVID-19 infection. If you have a current COVID-19 infection, you should wait until you are better and have completed your isolation time before coming in to get a COVID-19 vaccine. History of unprotected exposure to a person who tested positive for COVID-19 in the last 14 days

    If you have had an unprotected COVID-19 exposure, you should wait to complete your quarantine before coming in to geta COVID-19 vaccine.

    If you have been treated with a monoclonal antibody or convalescent plasma COVID-19 vaccination can be given at any interval following receipt of passive antibody therapy. Special populations: A COVID-19 vaccine may be administered to immunocompromised individuals, including people with HIV and those on immunosuppressive medications, but the vaccine has not been fully studied in this population. Women who are pregnant of breastfeeding should talk with their providers to decide on getting a COVID-19 vaccine. It is recommended to receive a COVID-19 primary series, additional mRNA doses (if indicated) and a booster. If you have any additional questions after reviewing the above information, talk to your doctor or healthcare provider before getting

  • Consent for Service

    I verify that I have been provided with and have read (or had read to me) (1) the Fact Sheet for Recipients and Caregivers for the Emergency Use Authorization (EUA) of the COVID-19 vaccine (“Vaccine”); (2) this COVID-19 Vaccination Consent and Release Form; and (3) any additional information provided to me concerning COVID-19 vaccination. I acknowledge that I have had a chance to ask questions of a healthcare professional about the vaccine. I understand that at this time, some COVID-19 vaccines require 2 doses given 21-28 days apart dependent on the manufacturer. If this is my first dose of the COVID-19 vaccine and a second dose is required, I intend to receive a second dose of the same vaccine in accordance with the timeframe specified in the Fact Sheet to complete the series. I understand the known risks and the potential benefits of receiving the vaccine, and I understand there may be risks to the Vaccine that are not known at this time. I understand that the FDA has authorized use of the vaccine under an Emergency Use Authorization (EUA). I understand Comirnaty is an FDA approved COVID-19 vaccine for those 16 years and older. I request and consent to the vaccine being given to me.
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  • Limitation of Liability

    I understand that, 5 Minute Pharmacy, its divisions and affiliates and their respective officers, directors, employees, agents and representatives are immune from civil liability under federal and state law for all claims for loss related to any known or unknown side effects and/or injuries, including but not limited to death, that I, or the person for whom I am authorized to make this request, may experience from this vaccine. This immunity means that if I file a lawsuit against 5 Minute Pharmacy, the court must dismiss any such lawsuit, and the only exception to this immunity is for claims for willful misconduct.
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  • Authorization to Release Information for Medication Treatment and/or Payment

    I understand that I am giving 5 Minute Pharmacy permission to release any medical or other information necessary to my physician, Medicare, Medicare HMO, or insurance company, as applicable, to enable 5 Minute Pharmacy to process my insurance claims with respect to the vaccination
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  • On your appointment day

    Please bring your vaccination card, proof of identification and insurance information (if available).
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