2022-08-24 - Flu and COVID-19 Vaccine Appointment Request and Consent Form

Vaccine Appointment Request and Consent Form
Pediatric Associates is excited to offer online appointment requests for Flu and COVID-19 vaccinations!

Our providers recommend all eligible children receive both the COVID-19 vaccine and the flu vaccine this season, even during the same visit.

If your child is not a current patient we will not be able to schedule an appointment through this form. Please CLICK HERE to request to become a patient!

We are able to administer the vaccine at all 3 offices however due to limited availability and storage requirements our satellite offices have limited availibility.

Please complete the form and we will contact you to confirm your request no later than 48 hours prior to your appointment.

We are offering a WEEKEND FLU CLINIC on limited dates at our MAIN office on Waters Avenue! Please select "MAIN OFFICE" then "WEEKEND CLINIC" to sign up!
Please select an office:*
Vaccine(s) Requested (select all that apply):*

Flu Vaccine

Main Office

4600 Waters Ave., Suite 100, Savannah, GA 31404
Waters Office Weekend Clinic - Select a date and time*
Waters Weekday Clinic - Select a date and time*
Pooler Office

110 Medical Park Drive, Pooler, GA 31322
Pooler Weekday Clinic - Select a date and time*
Pooler Weekend Clinic - Select a date and time*
Whitemarsh Island Office

1001 Memorial Dr, Savannah, GA 31410
Islands Weekday Clinic - Select a date and time*
Vaccine During Existing Appointment - Select the date and time of you child's upcoming appointment:*

Patient Information
Name*

First NameLast Name
Sex*

MaleFemale
Date of Birth*

MonthDayYear
Confirm age of recipient on the requested appointment date*

6 months old to 4 years old5 through 11 years old12 years old and older

COVID-19 Vaccine Consent
If you are unsure which vaccine dose your child requires please call our office before completing this form or review the CDC's recommendations at the links below:

General COVID-19 Vaccine information:

https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/children-teens.html

Booster Dose information:

https://www.cdc.gov/coronavirus/2019-ncov/vaccines/booster-shot.html#when-you-can-get-booster
Choose the COVID-19 vaccine dose needed:*

Start Primary Vaccine Series - Recipient has NEVER received any type of COVID-19 vaccine in the pastFinish Primary Vaccine Series - Has only received ONE dose of any COVID-19 Vaccine OR if 6 months to 4 years old has only received TWO doses of the Pfizer vaccineBooster Dose needed - Only for age 5 and older, over 5 months since completing, and has NOT had a booster dose already.Other (Second Booster, Third Dose of Primary Series for 5 or older): CALL OFFICE - Only children with specific medical conditions qualify
Recipient HAS experienced anaphylaxis (difficulty breathing) or severe allergic reactions from a previous vaccination OTHER THAN the COVID-19 vaccine or an injectable medication.- If YES, notify our staff immediately before the vaccine is administered as the patient will require 30 minutes of observation*

YesNo
Your child will receive either the Pfizer or Moderna vaccine based on availability and clinical guidelines, but if both are available you may list a preference below:*

Either Pfizer or ModernaPfizer (any patient 6 months or older)Moderna (only for ages 6 months to 5 years old)
I declare that the recipient:
- Has NOT had an allergic reaction* to the any of the following:
  An allergic reaction would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or caused the recipient togo to the hospital. It would also include an allergic reaction that caused hives, swelling, or respiratory distress, including wheezing
  - Polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures
  - Polysorbate, which is found in some vaccines, film coated tablets, and intravenous steroids
  - A previous dose of an mRNA COVID-19 vaccine
- I understand the recipient could be at increased risk of having a negative reaction or problem from the vaccine if any of the following are true:
  - Is currently sick with a fever, active respiratory infection or other moderate/severe illness and I will notify the office immediately if these symptoms occur at any point prior to the appointment
  - Is a female between ages 18 and 49 years old
  - Is a male between ages 12 and 29 years old
  - Has a history of myocarditis or pericarditis
  - Has 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-C or MIS-A) after a COVID-19 infection
  - Has a bleeding disorder
  - Takes a blood thinner
  - Has a weakened immune system (i.e., HIV infection, cancer) or take
    immunosuppressive drugs or therapies
  - Has a history of heparin-induced thrombocytopenia (HIT)
  - Is currently pregnant or breastfeeding
  - Has received dermal fillers
  - Has a history of Guillain-Barré Syndrome (GBS)
- I understand that the common risks associated with the COVID-19 vaccine include but are not limited to pain, redness or swelling at the site of injection, tiredness, headache, muscle pain, chills, joint pain, fever, nausea, feeling unwell or swollen lymph nodes (lymphadenopathy).
- I understand that the vaccine may cause a severe allergic reaction which can include anaphylaxis (difficulty breathing, swelling of the face and throat, a fast heartbeat, a rash all over the body, dizziness and/or weakness ). I understand that these may not be all the side effects of the COVID-19 vaccine as the vaccine is still being studied in clinical trials. I also understand that it is not possible to predict all possible side effects or complications which could be associated with the vaccine. I understand that the long-term side effects or complications of this vaccine are not known at this time.
- I have had the opportunity to speak with the recipients primary care provider prior to completing this form and am making an informed decision for the recipient to receive the vaccine
- I understand that the COVID-19 vaccine is a two-part vaccine series. By signing this consent, I am agreeing that I or my child will receive the first and second part of the vaccine series as scheduled
- I understand and agree that Pediatric Associates of Savannah, PC is required to submit COVID-19 vaccine administration data to the Georgia Registry of Immunization Transactions & Service (GRITS) and report moderate and severe adverse events following vaccination to the Vaccine Adverse Event Reporting System (VAERS).
- I understand that the vaccination is being given by Pediatric Associates of Savannah, PC. The owner and/or operator of this site, their affiliates, officers, directors, employees and agents expressly disclaim any responsibility for the vaccination. My consent is given in light of this knowledge, and in consideration of Pediatric Associates of Savannah, PC giving the COVID-19 vaccine. I, for myself and my heirs, administrators, trustees, executors, assigns and successors in interest do hereby agree to release and hold harmless Pediatric Associates of Savannah, PC, its subsidiaries, divisions, affiliates, successors, assigns, officers, trustees, employees, volunteers and agents from and against any and all demands, damages, losses, costs, expenses, obligations, liabilities, claims, actions and cause of action (whether any of which is groundless or otherwise) of any nature whatsoever (including, without limitation, reasonable attorney’s fees and court costs) by reason of or resulting, in any way, from any and all acts, accidents, events, occurrences, omissions and the like related to, or arising out of, directly or indirectly, my receipt of this COVID-19 vaccine. Pediatric Associates of Savannah, PC makes no warranties, express or implied, including but not limited to, implied warranties of merchantability or fitness for a particular purpose regarding the vaccine or its effectiveness.
- I agree to WAIT in the designated clinic location for 15 minutes after receiving the vaccine. If I or my child have previously had a severe allergic reaction to a vaccine or injectable medication, I agree to WAIT in the clinic location for 30 minutes after receiving the vaccine. I agree to seek immediate help for any concerns of a reaction.

Consent for vaccination
Signature of guardian (or recipient if over 18 years of age):*

Clear
Name of guardian (or recipient if over 18 years of age):*

First NameLast Name
Phone Number of guardian (or recipient if over 18 years of age):*
Please enter a valid phone number.
Email of guardian (or recipient if over 18 years of age):*

Confirmation Email
Appointment Request Summary
By clicking submit I agree to all of the above and I hereby give my consent to the staff of Pediatric Associates of Savannah, PC to give the recipient all vaccines requested. I understand the date and time of the appointment is not finalized and will wait for further confirmation from Pediatric Associates of Savannah, PC.
Should be Empty:

	Yes	No	Not Sure
1. Is the patient sick?
2. Does the patient have allergies to medications, food, a vaccine component, eggs, or latex?
3. Has the patient had a serious reaction to a vaccine in the past?
4. Has the patient had a health problem with lung, heart, kidney or metabolic disease (e.g., diabetes), asthma, or a blood disorder? Is he/she on long-term aspirin therapy?
5. Has a health care provider told you that the patient has had wheezing or asthma in the past 12 months?
6. If the patient is a baby, have you ever been told he or she has had intussusception?
7. Has the patient, a sibling, or a parent had a seizure; has the child had brain or other nervous system problems (e.g., Guillain-Barre syndrome)?
8. Does the patient have cancer, leukemia, HIV/AIDS, or any other immune system problem?
9. In the past 1-3 months, has the patient taken medications that affect the immune system such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatioid arthritis, Crohns's disease, or psoriasis; or had radiation treatments?
10. In the past year, has the patient received a transfusion of blood or blood products, or been given immune gamma globulin (IVIG) or an antiviral drug?
11. Is the patient pregnant or is there a chance she could become pregnant during the next month?
12. Has the patient received any vaccinations in the past 4 weeks?
13. Does the patient to be vaccinated live with or expect to have close contact with a person whose immune system is severely compromised and who must be in protective isolation (e.g., an isolation room of a bone marrow transplant unit)?
14. Has the person to be vaccinated ever had the following conditions: sickle cell disease, cochlear implant (receptient or candidate), damaged or no spleen, heart disease, kidney disease, lung disease, diabetes, alcoholism, cirrhosis, leaks of cerebrospinal fluid, or cancer?

Vaccine Appointment Request and Consent Form

Main Office

Pooler Office

Whitemarsh Island Office

Patient Information

Flu Vaccine Consent

COVID-19 Vaccine Consent

I declare that the recipient:

Consent for vaccination