Trumm Drug COVID-19 Vaccine Appointment and Consent
*Formulations may change due to availability*
NOTE: We have the Pfizer "updated booster" vaccine for BA.4/BA.5. Look here for updates on all COVID vaccine availability.
Date of Birth
Vaccine Recipient Physical Address
Street Address Line 2
State / Province
Postal / Zip Code
Please enter a valid phone number.
American Indian or Alaska Native
Black or African American
Native Hawaiian or Other Pacific Islander
Hispanic or Latino
Not Hispanic or Latino
Primary Care Provider Name
Emergency Contact Name:
Emergency Contact Phone Number
Relationship to Emergency Contact
Medicare B ID (Red/white/blue card)
Mother's Maiden Name (for MDH)
Which dose are you receiving:
Updated/Bivalent Booster Dose
If applicable, which vaccine did you last receive (choose one):
Total # of COVID-19 Vaccine doses received:
Date of last COVID-19 Vaccine
Which Trumm Drug Location:
Trumm Downtown Alexandria
COVID-19 Vaccine Screening Questions
1. Are you feeling sick today?
2. Have you ever had an allergic reaction to a component of the COVID-19 Vacccine, including Polyethylene glycol (PEG) or polysorbate or a previous dose of COVID-19 vaccine?
3. Have you ever had a reachion to another vaccine (other than COVID vaccine) or an injectable medication?
4. Have you ever had a sever allergic reaction (anaphylaxis) to something other than a component of COVID-19 vaccine, polysorbate, or any vaccine or injectable medication?
5. Is the person to be vaccinated have a health condition or undergoing treatment that makes
them moderately or severely immunocompromised? This would include, but not limited to,
treatment for cancer, HIV, receipt of organ transplant, immunosuppressive therapy or high-dose
corticosteroids, CAR-T-cell therapy, hematopoietic cell transplant [HCT], or moderate or severe primary
6. Have you previously received a COVID-19 vaccine before or during hematopoietic cell transplant (HCT) or CAR-T-cell therapies?
7. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? If yes, when did you receive antibody therapy:
8. Do you have a weakened immune system caused by something such as HIV infection or cancer or do
you take immunosuppressive drugs or therapies?
9. Do you have a bleeding disorder or are you taking a blood thinner?
10. Do you have dermal fillers?
11. Do you have a history of myocarditis or pericarditis?
12. Have you been diagnosed with Multisystem Inflammatory Syndrome?
13. Do you have a history of heparin-induced thrombocytopenia (HIT) or thrombosis with thrombocytopenia syndrome (TTS)
14. Do you have a history of Guillain-Barre Syndrome (GBS)?
15. Have you had COVID-19 in the past 3 months?
Additional vaccines requested at the same time (if eligible)
Influenza High Dose (65+ only)
Let me know what I need
None at this time
Consent (check each box below after reading and prior to signing the form)
Check all Boxes
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet (the Moderna Fact Sheet is available after clicking submit), a copy of which I was provided with this Consent Form. I have had a 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 Form.
I understand that at this time, the COVID-19 vaccine requires 2 doses given 21-28 days apart depending on the manufacturer. If this is my second dose, I will bring my vaccine card with me to be completed.
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.
I understand that I will be receiving the vaccination at no cost to me.
The vaccine is available to anyone no matter if insured or uninsured. Please check only one of the following.
If INSURED, check this box attesting to bringing in your prescription and medical insurance cards for your vaccine appointment. By selecting this, you are also authorizing the pharmacy to bill your insurance on your behalf for the immunization – understanding you will not incur any costs.
If UNINSURED, you must check this box to attest that the 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.
Should be Empty: