Flu Vaccine and Covid Vaccine Consent Form

Name*

First NameMiddle NameLast Name

Date of Birth*

Date

Phone Number*

Please enter a best contact phone number.

Residential Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Are you a Concord resident, age 60 or older?*

YesNo

You must be age 60 or older and a Concord, MA resident in order to sign up for this. If you are not, please contact West Concord Pharmacy and schedule your vaccine.

Gender*

MaleFemale

Email*

example@example.com

Primary Care Physician Name*

First NameLast Name

Primary Care Physician Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Care Physician Phone Number*

Please enter a valid phone number.

Do you have medical or pharmacy insurance?*

YesNo

Please bring in ALL cards that deal with your insurance (Private Insurance, Primary Insurance, Secondary Insurance, Medicare, Medicaid, Pharmacy and/or Medical). We will make copies of them at the clinic.

Please enter insurance information (leave field blank if unavailable). Information may be found on multiple insurance cards (Medical, Pharmacy, Medicare, Medicaid).


Insurance Name
Cardholder Name
Relationship to Cardholder
Member/Medicare/Medicaid ID
Medical Group Number
RX BIN
RX PCN
RX Group
RX ID (if separate card from Medical)

Which vaccine are you looking to get?

Appointment

Are you feeling sick today?*

YesNo

Are you pregnant or breastfeeding?*

YesNo

Have you ever had a seizure disorder for which you are taking seizure medication(s), a brain disorder, Guillain-Barre Syndrome (a condition that causes paralysis), or other nervous system disorder?*

YesNo

Have you ever had a severe allergic reaction (e.g. anaphylaxis, fainting or dizziness) to ANYTHING in the past? (For example, a reaction for which you were treated with epinephrine or for which you had to go to the hospital?)*

YesNo

Please list what you had a reaction to, especially anything related to vaccines:*

Note: You must have completed a primary series of a WHO- or FDA-approved Covid Vaccine in order to qualify for the Bivalent Booster Vaccine. If you have not completed a primary series, you cannot receive the Bivalent Booster Vaccine.

Note: Your last dose of ANY Covid Vaccine must be at least 2 months prior to receving your Bivalent Booster Vaccine. If it has not been at least 2 months, you cannot receive the Bivalent Booster Vaccine.

Race*

Ethnicity*

Please fill out completely:*


How Many doses of Covid Vaccine have you received?
Which Covid Vaccine(s) have you received?
When was you last dose? (MM/DD/YY)

Have you ever had a reaction to:*


Any dose of Covid Vaccine? (please describe)
Polyethylene glycol or Polysorbate?

Have you been diagnosed with multisystem inflammatory syndrome (MIS-C or MIS-A) after a Covid-19 infection?*

YesNo

Do you have a history of myocarditis or pericarditis?*

YesNo

Have you had monoclonal antibodies or convalescent plasma as part of a Covid-19 treatment in the past 90 days?*

YesNo

Do you have a bleeding disorder or are you taking a blood thinner? Do you have a history or at risk for blood clots?*

YesNo

You cannot recieve this or any Covid Vaccine at this time if you have recevied monoclonal antibodies or plasma for the treatment of Covid-19 in the 90 days preceeding this appointment date because the circulating antibodies will render the vaccine inactive. Please contact one of our pharmacies that is closest to you and we can schedule you appropriately.

Are you moderately or severely immunocompromised (ie: HIV, cancer treatment), a transplant patient, or taking immunosuppressant medication(s) (ex: anti-rejection medications, medications for RA, high-dose steroids)?*

YesNo

Please fill out completely:*


Have you received dermal fillers?
If yes, where on your body?

Covid Vaccine Consent Statement:

I have been provided with the Vaccine Information Sheet(s) or patient fact sheet corresponding to the vaccine(s) or EUA for COVID-19 vaccine that I am receiving. I have read the information provided about the vaccine I am to receive. I have had the chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of vaccination and I have voluntarily assumed full responsibility for any reactions that may result. I understand that I should remain in the vaccine administration area for a minimum of 15 minutes after the vaccination to be monitored for any potential adverse reactions. I understand if I experience side effects that I should do the following: call the pharmacy, contact my doctor and/or call 911. I request that the vaccine be given to me or to the person named above for whom I am authorized to make this request.

I do herby authorize The Pharmacy to release information and request payment. I certify that the information given by me in applying for payment under Medicare or Medicaid, Private Insurance or the HRSA COVID-19 program for Uninsured Patients, is correct. I authorize benefits be made on my behalf.

I understand that The Pharmacy may be required to or may voluntarily disclose my health information to the physician responsible for this protocol of specific health information of people vaccinated at The Pharmacy or at Clinics (if applicable), and/or my Primary Care Physician (if I have one), and/or my insurance plan, and/or health systems and hospitals, and/or state or federal registries such as Massachusetts Vaccine Registry (MIIS), for purposes of treatment, payment, or other health care operations (such as administration or quality assurance). I also understand that The Pharmacy will use and disclose my health information as set forth in the Notice of Privacy Practices (copy is available in-store, on-line or by requesting a paper copy from the pharmacy).

I do hereby consent the Pharmacy to submit vaccination data to state and federal vaccination registries.

Signature*

Clear

Signatory's Name*

First NameLast Name

Signatory's relationship to patient:*

PatientLegal GuardianAuthorized Representative

Date*

Date

By submitting this form, you agree that it has been filled out as completely and accurately as possible for all demographic information, billing information, and related questionnaire(s) and consent statement(s).

You will receive an email confirming your appointment date and time in the email provided in this form. Please make sure the email address is accurate. Emails will be generated by "noreply@jotform.com" once you have submitted this form, 1 day prior to your appointment, and 2 hours prior to your appointment. Please make sure to check your SPAM or JUNK folders in your email.

If you wish to change or cancel your appointment or if you have any questions about any of these vaccines, please contact Acton Pharmacy at: 978-263-3901.

Thank you

Acknowledgement*

I have read an understood the above statement

Covid Vaccine Consent Form

Demographic information

Insurance Information

Vaccine Information