Hawthorne: COVID Booster Vaccine Clinic

Vaccine Scheduling and Consent Form

Please read below carefully, fill out the form to the best of your knowledge. To space out appointment times and minimize wait times, we have created this HIPAA-secure electronic sign up form. There will be two clinic days- Thursday, October 6th and Thursday, October 20th. The clinics will take place from 9AM to 12PM in the Lemon Lime Room at the Hawthorne Clubhouse. We will be providing the new, bivalent booster doses for both Moderna and Pfizer COVID-19 vaccines (availability will depend on allotment by the federal government). Age appropriate flu doses will be available. If you would like a flu or booster dose sooner, we have vaccine appointments available at Burry's Pharmacy on Mondays and Tuesdays. To register visit burryspharmacy.com. If you have any questions about COVID-19 vaccines, please reach out to a staff member at Burry's Pharmacy, (352)787-3787.
Which vacinnation(s) does the patient need?*

Flu shot (influenza vaccine)COVID-19 vaccine (bivalent booster)BOTH flu and COVID-19 vaccines
Select the patient's age category below:*

Ages 12 to 17Ages 18 to 64Ages 65 and older
Which COVID bivalent booster does the patient need?*

PfizerModerna
Is this your first (1), second (2), or third (3), fourth (4), or fifth (5), or sixth (6) dose of the COVID-19 vaccine?*

123456
Dose acknowledgement (select which dose you qualify for below):*

Pfizer Bivalent Booster: 12 years and older (at least 2 months after previous booster)Moderna Bivalent Booster: 18 years and older (at least 2 months after previous booster)
What was the date of your most recent COVID vaccine?

MonthDayYear
Date
Which arm would you like to receive your shot?

Right armLeft arm
Are you a shut-in (handicapped or disabled) who will require an in-home vaccine?*

Yes- I will require an in-home visit (taking place in the afternoon on October 20th)No- I will attend the clinic at the Lemon Lime Room
Appointment Date and Location

Thursday, October 6th and Thursday, October 20th: Lemon Lime Room
Please select an appointment time. *
Patient Demographic Information
Name*

FirstNameLastName
Date of Birth*

MonthDayYear
Date
Gender*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com (We will send a confirmation and reminder email here)
Home Address*

AddressOne

AddressTwo

CityStateCode

Zip
Race*
Ethnicity *
Patient Prescription Insurance
Do you have health insurance?*

Yes, I DO have health insuranceNo, I DO NOT have health insurance (uninsured)
Rx BIN*
This information is found on your PRESCRIPTION insurance card
Rx PCN*
This information is found on your PRESCRIPTION insurance card
Rx GROUP ID*
This information is found on your PRESCRIPTION insurance card
Member ID*
This information is found on your PRESCRIPTION insurance card
Medicare Part B ID (If 65 years or older or have Part B coverage)
Red White & Blue Card
Emergency Contact Information
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
Emergency Contact Relationship
Patient Medical History

	Yes	No	Don't Know
Have you experienced a serious reaction after getting a vaccine?
Do you have allergies to medication, food, a vaccine component, or latex?
Do you have cancer, leukemia, HIV/AIDS, or other immune system problems?
During the past year have you received a transfusion of blood, blood products, immune (gamma) globulin, or an antiviral drug?
Have you received any vaccinations in the past 4 weeks?

Vaccine Acknowledgement
The COVID-19 vaccine will reduce the risk of suffering from the new type of Coronavirus disease as known as COVID-19.

Please be aware that the vaccine is not completely effective like all other medicines. It can take a few weeks for your body to build up protection from the vaccine. There is always a chance of getting infected by Coronavirus even with the vaccine; however, the vaccine lessens the severity of any infection. A dose will reduce the chance of being seriously ill and reduce the risk of death due to Coronavirus.

This vaccine does not give you COVID-19 infection, but you still need to follow the health instructions in your workplace and in public areas, such as wearing a mask and keeping a distance from others.

The vaccine has some side effects as the other vaccines/medicines, but not everyone gets them.

The most likely side effects that you may experience from the vaccine:
- Fever
- Pain at the injection site
- Redness and hardness of the skin at the injection site
- Headache
- Muscle aches or pain
- Joint aches or pain
- Fatigue (tiredness)
- Nausea/vomiting
- Chills
- Underarm gland swelling on the side of vaccination
If you are currently pregnant or planning to get pregnant or your partner is planning to get pregnant; please see your doctor before getting vaccinated.

Any patient receiving testing, screening, or treatment services is advised to seek follow up care from his or her primary care physician.

By signing this form I hereby accept that:
- I have read and understood the acknowledgment letter provided above.
- I declare that the information I have provided above is correct.
- I am giving my full consent to get the flu and/or COVID-19 vaccine of my own will.
- I will show up ON TIME for my appointment
- I have been provided with the Vaccine Recipient Fact Sheet (Moderna- https://eua.modernatx.com/covid19vaccine-eua/eua-fact-sheet-recipients.pdf) (Pfizer- https://www.fda.gov/media/153716/download)
- I have been provided with information about the CDC's V-safe After Vaccination Health Checker (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/vsafe.html )
Date of Form Completion*

MonthDayYear
Date
Signature

Clear
If you have any additional questions, please list them here and a team member will follow up with you.
Thank you to the AARP Hawthorne Chapter 1775 for sponsoring this event and to Rebecca (Hawthorne Program Coordinators) for helping to coordinate!
Should be Empty:

Vaccine Scheduling and Consent Form

Appointment Date and Location

Patient Demographic Information

Patient Prescription Insurance

Emergency Contact Information

Patient Medical History

Vaccine Acknowledgement