Southern Drug Company - All Vaccines Electronic Consent Form

Southern Drug Company - All Vaccines Electronic Consent Form
ALL VACCINES - ADULT AND PEDIATRIC - INFORMED CONSENT FORM
PATIENT INFORMATION
First Name*
Last Name*
Date of Birth*

MonthDayYear
Date
Age*
Phone Number*
Email*
example@example.com
Address*

Address

Street Address Line 2

CityState

Zip Code
Gender*

MaleFemale
Race (White, Black, Asian, Pacific Islander, Etc)*
Ethnicity (Hispanic or Non Hispanic)*
Social Security Number*
Medicare Number (If applicable) - If no Medicare Number, type "N/A"*
Primary Care Dr*
City/State*
Mother's Maiden Name*
Which vaccine(s) are you requesting today?
Which vaccine(s) are you requesting today? Please select all that apply*

COVIDFlu (65 years and up)Flu (13-64 years old)Shingrix (Shingles)Prevnar (Pneumonia)Pneumovax (Pneumonia)Boostrix (TDaP - Tetanus/Diptheria/Pertussis)
Have you received a COVID-19 vaccine in the past?*

YesNo
If Yes, Which dose will this vaccine be for you?

1st Dose2nd Dose3rd Dose (Additional dose for immunocompromised only)Booster Dose
What was the date of your last COVID vaccine?

MonthDayYear
Date
Which COVID Vaccine Would you like to receive?

Moderna OMICRON BOOSTER (Bivalent) 18+Pfizer OMICRON BOOSTER (Bivalent) 12+Moderna - (12+ Primary Series)Pfizer - (12+ Primary Series)Moderna - (6-11 Years Old)Pfizer - (5-11 Years Old)Moderna - (6 months - 5 years old) *SDC can only vaccinate 3 years and up*Pfizer - (6 months - 4 years old) *SDC can only vaccinate 3 years and up*Janssen (18+ Primary Series)
Vaccine Screening Questions

Please answer these questions to the best of your ability
What was the date of your last physical?
What was the date of your last influenza vaccine?
Have you received a Pneumonia vaccine in the past 5 years?

YesNo
Have you received a Shingles vaccine or been diagnosed with Shingles in the past 12 months?

YesNo
Have you received a Meningitis vaccine?

YesNo
Have you taken any antiviral treatment in the past 24 hours?

YesNo
Please list any Prescription or Over-The-Counter medications you are taking (If you are an established SDC patient, we can look up your profile - Please write "SDC PATIENT"
Are you feeling sick today?

YesNo
Have you ever had an allergic reaction to any food, any vaccine, a previous covid vaccine or a component of a COVID-19 vaccine (including Polyethylene glycol (PEG), which is found in medications, such as laxatives and preparations for colonoscopy procedures, or polysorbate, which is found in some vaccines, film coated tablets, and intravenous steroids)?

YesNoI Don't Know
Do you carry an Epipen?

YesNoI Don't Know
Do you have a history of myocarditis or pericarditis?

YesNoI Don't Know
Have you been diagnosed with Multisystem Inflammatory Syndrome (MIS-C or MIS-A) after a COVID-19 infection?

YesNoI Don't Know
Do you have a weakened immune system (i.e., HIV infection, cancer) or take immunosuppressive drugs or therapies?

YesNoI Don't Know
Do you have a bleeding disorder or take a blood thinner?*

YesNoI Don't Know
For Women: Are you pregnant or breastfeeding?*

YesNoI Don't Know
Have you received dermal fillers?*

YesNoI Don't Know
Do you have a history of Guillain-Barre Syndrome (GBS)?*

YesNoI Don't Know
Are you allergic to chicken eggs or egg products?*

YesNoI Don't Know
Are you allergic to thimerosal (cleaning products or contact lens solution)?*

YesNoI Don't Know
Have you received any other vaccinations in the past 4 weeks?*

YesNoI Don't Know
Do you have long term health conditions, such as heart, liver, kidney, lung, metabolic disease, neuromuscular or neurologic disease, anemia or other blood disorder?*

YesNoI Don't Know
Are you Diabetic or do you have Diabetes or Pre-Diabetes?*

YesNoI Don't Know
Vaccine Information Sheets (VIS) and Emergency Use Authorizations (EUA) & Notice of Privacy Policies
Influenza VIS

Prevnar VIS

Pneumovax VIS

Shingles VIS

TDaP (Tetanus/Diptheria/Pertussis) VIS

COVID (Moderna 12+ Primary and Bivalent) EUA

COVID (Moderna 6-11 years) EUA

COVID (Moderna 6 mo - 5 years) EUA

COVID (Pfizer 12+ Primary and Bivalent) EUA

COVID (Pfizer 5-11 years) EUA

COVID (Pfizer 6 mo - 4 years) EUA

COVID (Janssen 18+) EUA
Vaccine Acknowledgements
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 & Release. I have had the 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 & Release.*

Agree
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 & of my rights with respect to my health to my health information.*

Agree
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.*

Agree
I voluntarily request and consent that a pharmacist/technician employed by Southern Drug Company, Inc (SDC) administer to me the vaccine(s) ("Vaccine") I requested above.*

Agree
I have truthfully answered all the questions regarding my medical history that are listed above. I understand that if I answered a question with a "yes" there is an increased likelihood that I will experience an adverse reaction from the administration of the vaccine. After careful consideration, I believe that the benefits of receiving the vaccine(s) outweigh the risks associated with receiving the vaccine(s) and I have decided to have the SDC pharmacist/technician administer the vaccine(s) to me.*

Agree
If applicable, I authorize SDC to submit a claim to my insurer for this service and authorize an assignment of my insurance benefits under such claim to SDC. I will be financially responsibile for any copays, coinsurance, & deductibles for the requested services as well as for any services not covered by my insurance benefits. I authorize SDC to use and/or disclose such information about me, including any medical related information that I provided to SDC or that is created or received by SDC that SDC reasonably determines is necessary to receive payment for its services, carry out my treatment or conduct its health care operations. This authorization includes disclosures to regulatory agencies, Medicare, Medicaid, health plans, pharmacy benefit managers, claims processor, billing companies, interpreters, & other persons involved in my treatment, as well as any state immunization registry. SDC shall not, at any time, or to any extent allowable by applicable law, be liable, responsible, or in any way be accountable for any loss, injury, death, or damage suffered or sustained by me or any other person at any time in connection with, or as a result of, the administration of the vaccine(s) to me by the SDC pharmacist. I, for myself, my heirs, executors, personal representatives & assigns, hereby release SDC, its employees & contractors, specifically the administering pharmacist/technician, its agents, or representatives from any and all claims arising out of, in connection with, or in any way related to my receipt of the vaccine(s) from SDC as allowed by applicable law.*

Agree
By signing below, I certify that I am the patient or the patient's guardian/personal representative signing on behalf of the patient, & that I have read, understand, and agree to all the statements on this form.
Signature of Person to Receive Vaccine*

Clear
DATE*

MonthDayYear
Date
Parent/Guardian name and Relation to Patient (if Recipient is a Minor)
Please choose your appointment time:
Should be Empty:

Southern Drug Company - All Vaccines Electronic Consent Form

ALL VACCINES - ADULT AND PEDIATRIC - INFORMED CONSENT FORM

PATIENT INFORMATION

Which vaccine(s) are you requesting today?

Vaccine Screening Questions

Vaccine Information Sheets (VIS) and Emergency Use Authorizations (EUA) & Notice of Privacy Policies

Vaccine Acknowledgements