Leeland COVID-19 Consent Form 2022

Do you feel sick today?*

YesNoDon't Know or N/A

Have you had COVID-19 within the last three months?*

YesNoDon't Know or N/A

Do you have a history of an immune-mediated syndrome defined by thrombosis and thrombocytopenia, such as heparininduced thrombocytopenia (HIT)?*

YesNoDon't Know or N/A

Do you have a history of thrombosis with thrombocytopenia syndrome (TTS)?*

YesNoDon't Know or N/A

Have you been diagnosed with Multisystem Inflammatory Syndrome (MIS-C or MIS-A) after a COVID-19 infection?

YesNoDon't know or N/A

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?*

YesNoDon't Know or N/A

Do you have an allergy to any food, medication or vaccine?*

YesNoDon't Know or N/A

Please specify allergy

Have you ever had a serious reaction or fainted after receiving any vaccination?*

YesNoDon't Know or N/A

Do you carry an EpiPen?*

YesNoDon't Know or N/A

Do you have a bleeding disorder or take a blood thinner?*

YesNoDon't Know or N/A

Have you ever had a seizure, brain disorder, or Guillain-Barre Syndrome?*

YesNoDon't Know or N/A

Do you have a weakened immune system (i.e., HIV infection, cancer) or take immunosuppressive drugs or therapies?*

YesNoDon't Know or N/A

Do you have a history of myocarditis or pericarditis?*

YesNoDon't Know or N/A

Have you received hematopoietic cell transplant (HCT) or CAR-T-cell therapies since receiving COVID-19 vaccine?*

YesNoDon't Know or N/A

FOR WOMEN: Are you currently pregnant or breastfeeding?*

YesNoDon't Know or N/A

Pfizer (12+) VIS Pfizer (5-11) EUA Pfizer (6mo-4yr) EUA Moderna (12+) EUA Moderna (6-11) EUA Moderna (6mo-5yr) EUA Janssen (18+) EUA Novavax (12+) EUA Notice of Privacy Practices

Acknowledgements*

I attest that the answers provided here are accurate to the best of my knowledge.I understand the benefits and risks of the vaccination(s) as described in the Vaccine Information Sheet (VIS) or Emergency Use Authorization (EUA), a copy of which I was provided with this Consent &amp; 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 &amp; Release.I have received a copy of the notice of Privacy Practices. 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 &amp; 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.

Insurance Information

I hereby authorize the pharmacy to bill my insurance on my behalf for the COVID-19 vaccine administration fee & receive payment.Please mark here if you do not have insurance and provide your social security number or driver's license number.

Social Security Number

Driver's License Number

Insurer

Member #

Rx Group

BIN #

PCN #

Signature of Patient to Receive Vaccine (or Signature of Power of Attorney or Legal Guardian)

Date

Parent/Guardian Name

Relationship to patient

After submitting, you will be redirected to schedule your appointment. Please make sure to confirm your appointment so we save your spot on our schedule. If you are scheduling for COVID-19 and another vaccine, please only make the COVID-19 appointment. If there are no appointments available for the vaccine you need, please check back.

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.

COVID-19 VACCINE INFORMED CONSENT FORM

Patient Information

IMMUNOCOMPROMISED

MONOVALENT BOOSTER

UPDATED BOOSTER

REASONS TO STOP FORM

Screening Questions