Lopez Island Pharmacy New Covid Vaccination Questionnaire COVID Sept. 2023 Ver 1.8

If you do NOT have an appointment for COVID-19 vaccine do NOT fill out a consent form.

Only fill out this form if you have an appointment ALREADY scheduled.
Patient Name (Who is receiving the vaccination)*

First NameMiddle NameLast NameSuffix
Birth Date:*

MonthDayYear
Date
Sex at birth*

MaleFemale
Are you pregnant or breastfeeding, or do you plan to become pregnant?*

YesNo
What Trimester are you in, or breastfeeding?
Phone Number*
Mobile Phone
Email
example@example.com
Are you under age 65?*
Enter Employer name, if none type "None"
Race?*
Ethnicity?*
Preferred method of contact for second/booster vaccination?*

I do not have any insurance, including but not limited to Medicare, Medicaid, OR any other private or government-funded health benefit plan. In order to have your vaccine administration fee paid for by the United States Health Resources & Services Administration’s COVID-19 Program for Uninsured

Yes (You do NOT have any insurance)No
Enter at least one of the following, you MAY enter more than one if you choose.
Social Security Number (WITHOUT DASHES ex. 123456789)
Driver's License Number and State of Issuance
Enter your Drivers License Number and the State where it was issued
Is Lopez Island Medical Center your "Primary Provider"?*

YesNo
Then please enter your "Primary Care" provider name and phone number.
Enter your Primary Care provide and phone number.

Acknowledgements

I made the choice to get the COVID-19 vaccine on my own and freely. I know I have the option to refuse the vaccine. I ask that the vaccine be given to me, or to the person named above for whom I can make this request. I was given the (Fact Sheet for Vaccine Recipients and Caregivers-EUA) for this vaccine. The fact sheet has information about side effects and adverse reactions. I read or had read to me the information provided about the COVID-19 vaccine from the EUA sheet. I understand that my information will be stored electronically in the Washington Immunization and Information System (WAISS)

   I know the Food and Drug Administration (FDA) has authorized the emergency use of this vaccine. I know it is not a fully licensed FDA vaccine. I had the chance to ask questions that were answered to my satisfaction. I now know about the vaccine, alternatives, benefits, and risks, to the extent they are known and unknown at this time.

   I know that I must stay in the vaccine area or an area told to me by my health care provider after I receive my immunization so I am near my health care provider if I have any adverse reactions. If I have a history of severe allergic reaction, (e.g. anaphylaxis), I must stay for 30 minutes. If I do not have a history of severe allergic reaction, I must stay for 15 minutes

   I know that if I have a severe allergic reaction, including difficulty breathing, swelling of my face and/or throat, a fast heartbeat, a bad rash all over my body or dizziness and weakness I should call 9-1-1 or go to the nearest hospital. I know I can call my health care provider if I have any side effects that bother me or do not go away.

I was asked to join the V-SAFE program. The program does health checks on the people who get the COVID-19 vaccine. I know I should report vaccine side effects to FDA/CDC Vaccine Adverse Event Reporting System (VAERS) at 1-800-822-7967 or https://vaers.hhs.gov/reportevent.html.

   I know I must get two doses of the COVID-19 vaccine and receive the same vaccine each time. I know that with all vaccines there is no promise I will become immune (not get the virus) or that I will not have side effects. I know I may choose to not get the second dose of the vaccine. But if I do not get the second dose, the chance that I will become immune may go down.
Authorization to Request Payment:

I authorize the organization providing my vaccine to release information and request payment. I certify that the information given by me in applying for payment under Medicare or Medicaid or the HRSA COVID-19 Program for Uninsured Patients, is correct. I authorize release of all records to act on this request. I request that payment of authorized benefits be made on my behalf.

Disclosure of Records: I understand the organization providing my vaccine may be required to or may voluntarily disclose my vaccine-related health information to my primary care physician, my insurance plan, health systems and hospitals, and state or federal registries or other public health authorities, for purposes of treatment, payment or health care operations. I also understand the organization providing my vaccine will use and disclose my health information as described in its Notice of Privacy Practices which I may receive upon request or find on its website . If I am an employee of Lopez Island Pharmacy(LIP) I understand that it will keep records of this vaccination for me in Pioneer Pharmacy Database and may keep my vaccination records in LIP's Electronic Medical Records sytem employee occupational health records, to the extent required or permitted by law. Lopez Island Pharmacy does not discriminate.
All vaccinations are submitted to the Washington State Health Department Vaccination Database UNLESS you specifically opt out.*

I consent to this vaccination being submitted to the Department of Health DatabaseI do NOT consent to my vacciantion being sent to the Department of Health Database
After signing with your mouse or fingertip(if using a tablet or phone) don't worry how it looks, press "SUBMIT", the form will be sent electronically to us, you do NOT need to print out this form
Patient Signature *

Clear
Date*

MonthDayYear
Date
Press "Submit" to finish...DO NOT PRESS "NEXT"

If you receive a large green check mark you have completed this form.

Forehead Temperature: ____________ F.

Lot Number: _____________ Expiration Date: ___/___/___ *

Administration Date: ___/___/___

Route: IM ONLY for Moderna

Admin Site: Left Deltoid Right Deltoid Other:________

Date this record was entered into WA Register: __________________

Vaccine Administered by:____________________________

Notes:

You must be 65 years or older for this vaccine or immunocomprimised.

OR

Unsure of the dates of your previous Covid-19 Vaccination.

Have your appointment already scheduled, if not please schedule your appointment first and then come back to this form.
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