If you have any questions, please call us at (3
Section I. Personal Information
Patient's Full Name:
Date of Birth:
Medicare Part B Number (Red, White and Blue card):
Please enter your Medicare Part B number even if you have Medicare Advantage or other insurance.
Are you moderately to severely immunocompromised?
Second doses of Bivalent COVID-19 vaccines are only eligible for individuals 65 and older or who are moderately to severely immunocompromised.
Please check back at a later date to see if you are eligible.
Hispanic or Latino
Prefer not to answer
Native Hawaiian/Other Pacific Islander
Prefer not to answer
Street Address Line 2
District of Columbia
Primary Care Doctor:
What dose of COVID-19 vaccine will this be?
When did you receive your last dose?
Section II. Questionnaire for Immunization
Please select the correct option below:
Don't know or N/A
COVID-19 Screening Questions:In the past two weeks, have you tested positive for COVID-19 or are you currently being monitored for COVID-19?
In the past two weeks, have you had a known exposure with anyone who tested positive for COVID-19?
Have you had a new onset of fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, nausea, vomiting, or diarrhea?
Questionnaire for Immunization: Do you feel sick today?
Do you have an allergy to medications, foods, or any vaccines (eggs, gelatin, thimerosal, neomycin, gentamicin, latex, aluminum, preservatives, baker's yeast, etc.)?
Do you carry an EpiPen?
Have you been diagnosed with or suspected of having covid in the last 90 days?
If yes to the above question, did you receive medications, plasma or other treatment?
Have you ever had a serious reaction or fainted after receiving any vaccination?
Have you ever had a seizure, brain disorder, or Guillain-Barre Syndrome?
Have you received any other immunizations in the last 14 days?
For women: Are you pregnant or are you planning on becoming pregnant during the next month?
Please specify the allergy from Q2:
Section III. Appointment Scheduler
**Vaccine supply is limited. Please keep your appointment or call if you need to cancel or change it. Additionally, due to vaccine requirements; we may call you to see if you can come earlier, later or to a nearby location. If you miss an appointment, no doses will be held to guarantee your dose.**
Please pick a day and time for your vaccination
Section IV. Signatures
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) (insert link to EUA), a copy of which I was provided with this Consent and Release. 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, a minor for whom I represent that I am authorized to sign this Consent and Release.
Signature of Person to Receive Vaccine & EUA/VIS (or Signature of Parent/Guardian if Patient is < 18 yo)
I have received a copy of the notice of
. I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.
Signature of Acknowledgment of Notice of Privacy Practices:
Please take or upload pictures of front & back of insurance card for billing purposes
I authorize the pharmacy to bill my insurance on my behalf for the immunization and the information provided is true and accurate.
If uninsured, you must check the box below to attest that the following information is true and accurate
I do not have any insurance, including but not limited to Medicare, Medicaid or any other private or government-funded health benefit plan
You may be charged a vaccine administration fee of up to $20.00
By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.
Should be Empty: