COVID19 Vaccine Consent Form

Moderna COVID-19 Vaccine Consent Form
Select an appointment time. Appointments will be held at Brehme Drug, 220 East Main Street, Manchester IA 52057.*
Please re-enter the appointment date and time selected above.*

MonthDayYear
Date
Hour MinutesAM/PM Option

Patient Information

Vaccine Recipient
Vaccine Recipient Name*

First NameLast Name
Date of Birth*

MonthDayYear
(Vaccine recipient must be 18 years of age or older to receive the Moderna Bivalent vaccine)
Sex at Birth*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Race*
Ethnicity*
Primary Care Provider Name
Mother's Maiden Name
Emergency Contact Name

First NameLast Name
Emergency Contact Relation
Emergency Contact Phone Number
Please enter a valid phone number.

Select the vaccine receiving:*

Moderna (Spikevax) 2023-24 Formula
Please select other vaccine(s) you would like at the same appointment as the COVID vaccine:

InfluenzaPneumoniaRSVTetanus/Whooping coughShingles

	Check each box
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet, a copy of which I was provided with this Consent Form. I have had a change to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, for whom I represent that I am authorized to sign this Consent Form.
I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.
If INSURED, check this box attesting to bringing in your prescription & medical insurance cards. By selecting, you are also authorizing the pharmacy to bill your insurance on your behalf.
If UNINSURED, you must check this box 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 benefit plan.

Payment

Vaccines may be billed to your pharmacy benefits. Please contact your plan directly if you have questions regarding insurance coverage of vaccines.
Chose a payment method

My insurance is already on fileCommercial InsuranceMedicarePay Out of Pocket (no insurance)
Insurance Card Information

Please input each of the following from your commercial / Medicare Part D insurance card.
BIN
PCN
ID
Rx Group
Take photo of your Medicare A/B Card or prescription insurance card (if you do not have Medicare).
Medicare A/B Number

Signature of Person to Receive Vaccine & EUA/VIS (or Signature of Parent/Guardian if Patient is < 18 years old):*

Clear
Date Signed*

MonthDayYear
Date
Should be Empty:

	Yes	No	Unsure
Are you feeling sick today?
Have you ever had an allergic reaction to a component of the COVID-19 vaccine, including polyethylene glycol (PEG) or polysorbate or a previous dose of COVID-19 vaccine?
Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication? (This would include a severe allergic reaction [eg. anaphylaxis] that required treatment with epinephrine or EpiPen(R) or that caused you to go to the hospital. It would also include an allergic reaction that caused hives, swelling, or respiratory distress, including wheezing.)
Have you ever had a severe allergic reaction (eg. anaphylaxis) to something other than a component of COVID-19 vaccine, polysorbate, or any vaccine or injectable medication? This would include food, pet, venom, environmental, or oral medication allergies.
Do you have a bleeding disorder or are you taking a blood thinner?
Do you have a history of myocarditis or pericarditis?
Have you been diagnosed with Multisystem Inflammatory Syndrome?
Do you have a history of heparin-induced thrombocytopenia (HIT) or thrombosis with thrombocytopenia syndrome (TTS)?
Do you have a history of Guillain-Barre Syndrome (GBS)?

Moderna COVID-19 Vaccine Consent Form