Trumm Drug COVID-19 Vaccine Appointment and Consent
*Formulations may change due to availability*
NOTE: At this time, we have the Pfizer "updated booster" vaccine for BA.4/BA.5. Look here for updates.
We also have the original Moderna for initial series
First Name
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Last Name
*
Date of Birth
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Month
-
Day
Year
Date
Gender
*
Please Select
Female
Male
Non-binary
Vaccine Recipient Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Race
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Ethnicity
*
Please Select
Hispanic or Latino
Not Hispanic or Latino
Unknown
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:
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1st Dose
2nd Dose
Additional Dose
Updated/Bivalent Booster Dose
If applicable, which vaccine did you last receive (choose one):
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Pfizer
Moderna
Janssen
Novavax
COVID-19 Vaccine doses received:
*
Date of last COVID-19 Vaccine
*
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Month
-
Day
Year
Date
Which Trumm Drug Location:
*
Please Select
Trumm Downtown Alexandria
Appointment
COVID-19 Vaccine Screening Questions
*
Yes
No
Dont Know
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
immunodeficiency.
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)
Please Select
Influenza
Influenza High Dose (65+ only)
Shingles (Shingrix)
Pneumonia
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.
Friendliness
The vaccine is available to anyone no matter if insured or uninsured. Please check only one of the following.
*
Check one
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.
Signature
Clear
Date Signed
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Month
-
Day
Year
Date
Submit
Should be Empty: