Moderna COVID Vaccine w/ Influenza option

Please choose a date and time for your COVID Vaccine Appointment*

Time

Hour Minutes

AM/PM Option

Your appointment will be for the following manufacturer:

PERSONAL INFORMATION (please record your name exactly as shown on your insurance card)

Name

First NameLast Name

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth

Date

Age

Gender

Weight

Enrolled in Hospice?

Phone Number

Please enter a valid phone number.

Primary Care Doctor:

Medicare Part B ID, Insurance ID, or Social Security Number:

Ethnicity

Race

Screening Questions:

Are you sick today? (fever, cough, shortness of breath, nausea/vomiting in the last 24 hours)

Have you received a previous dose of the COVID-19 vaccine? Be prepared to show your card/documentation, date(s) received & brand.

Have you ever had a severe allergic reaction that required treatment with epinephrine/EpiPen or that caused you to go to the hospital, or that caused hives, swelling, wheezing, or respiratory distress to any of the following: A COVID-19 vaccine component (including polyethylene glycol (PEG), polysorbate, a previous dose of COVID-19 vaccine, another vaccine, or injectable medication, or anything else? This would include food, pet, venom, environmental, or oral medication allergies.

If yes, what was the allergy to?

Does the person to be vaccinated have a health condition or undergoing treatment that makes them moderately or severely immunocompromised, or have a weakened immune system? This would include, but not limited to, treatment for cancer, HIV, receipt of organ transplant, immunosuppressive therapy or high-dose corticosteroids, CAR-T-cell therapy, hematopoietic cell transplant [HCT], or moderate or severe primary immunodeficiency.

Have you been diagnosed with Multisystem Inflammatory Syndrome (MIS-C or MIS-A)?

Do you have a history of myocarditis or pericarditis?

Have you received antibody therapy (monoclonal antibodies or convalescent serum) to treat COVID-19?

Do you have a bleeding disorder or are you taking a blood thinner?

Do you have dermal fillers?

Do you have a history of heparin-induced thrombocytopenia or thrombosis with thrombocytopenia syndrome?

Do you have a history of Guillain-Barre Syndrome (GBS)?

Have you had COVID-19 in the past 3 months?

Which dose are you receiving today?

Very first dose of any COVID VaccineBooster dose

Manufacturer of previous dose:

Date of last dose

Date

Please visit the CDC website cdc.gov/coronavirus/2019-ncov/vaccines/index.html to learn about the benefits and risks (VIS) of the COVID-19 vaccine. Please visit our website or click to read our Privacy Policy (PP) By signing below, you agree that 1) you reviewed both the VIS and PP, 2) you understand the benefits and risks of the vaccine and you are asking that the vaccine be given to you or the person named on this form for whom you are authorized to make this request 3) consent that we can bill your insurance, if applicable, 4) you authorize the release of this vaccination record and all information on this form to your state's Immunization Program and the CDC, and 5) we can you release this record to your doctor, school, or employer if requested. If the person who is being vaccinated is age 17 or under, by signing below you agree that you are authorized to consent to the vaccination of the patient and the patient on this form may receive vaccine with or without you, as the parent or guardian, present at the time of vaccination. After receiving your vaccine we recommend you wait at least 15 minutes. If you leave the vaccination site before 15 minutes has passed, you assume any risks associated with not waiting the recommended amount of time. If you are receiving an "additional" dose, you attest that you are doing so due to having a weakened immune system. If you are age 12-49 and are requesting a 2nd booster, you attest that you are doing so due to having a weakened immune system. You consent to receive the vaccine in a public location.

Signature

Would you like to also receive an influenza vaccine at your appointment?*

YesNo

Did you have a flu shot last year?

Do you have allergies to Medications, eggs, or any vaccine components?

Have you ever had a serious reaction after receiving a vaccination?

Do you have cancer, leukemia, HIV/AIDS, or any other immune system problems?

In the past 3 months, have you taken medications that weaken your immune system, such as cortisone, prednisone, other steroids, anticancer drugs, or had radiation treatments?

During the past year, have you received a transfusion of blood or blood products, or been given a medication called immune globulin?

Is it possible you are pregnant, or plan to become pregnant in the next three months?

I have read or have had explained to me the information in the important information statement about influenza vaccine. I have had a chance to ask questions that were answered to my satisfaction. I believe I understand the benefits and risks of influenza vaccine and ask that the vaccine be given to me or the person named above for whom I am authorized to make this request.FOR MEDICARE & INSURANCE RECIPIENTS: I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment.

I agree to the above statements

Signature

PERSONAL INFORMATION for Influenza Form

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth

Date

Age

Gender

Weight

Enrolled in Hospice?

Phone Number

Please enter a valid phone number.

Primary Care Doctor:

Medicare Part B ID, Insurance ID, or Social Security Number:

Are you sick today? (fever, cough, shortness of breath, nausea/vomiting in the last 24 hours)

Date

INFLUENZA SCREENING QUESTIONS

Influenza Vaccination Form