• 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.
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  • Appointment Date and Location

    Thursday, October 6th and Thursday, October 20th: Lemon Lime Room
  • Patient Demographic Information

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  • Patient Prescription Insurance

  • Emergency Contact Information

  • Patient Medical History

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  • 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 ) 

     

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  • Thank you to the AARP Hawthorne Chapter 1775 for sponsoring this event and to Rebecca (Hawthorne Program Coordinators) for helping to coordinate!
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