PAD/ Carpe Diem Health COVID-19 Vaccine Registration (January, February and March 2023)

with Carpe Diem Health PLLC

A Texas COVID-19 Vaccine Provider
COVID-19 Vaccine Registration and Consent Form

Vaccination Clinic at Pediatric Associates of Dallas
01/03/23 Update.

PFIZER BIVALENT (6 mo- 4 years) is now available. This bivalent dose will replace shot #3 in the COVID vaccination series. Please note, this is not authorized as a booster dose for children who have already received 3 doses in the Pfizer (6 mo - 4 year) series. Those children should not sign up for a bivalent vaccine as they are considered fully immunized by the current guidelines.

MODERNA BIVALENT BOOSTER (6 months - 5 years) is now available.

Who is eligible for this? Children ages 6mo - 5 years that received both doses of the Moderna vaccination series and their second dose was at least 8 weeks ago.

The Moderna 6 mo- 5year serires is now: Dose 1 (original). 4 weeks later Dose 2 (original). 8 weeks later : Moderna bivalent booster

If your child has received doses 1 and 2 of Pfizer 6 mo - 4 years, your 3rd dose will now be the Pfizer 6 mo-4 year bivalent vaccine. This will be given at least 8 weeks after the second original dose in the series was received.

Pfizer 6mo- 4year series is now: Dose 1 (original). 3 weeks later Dose 2 (original). 8 weeks later Dose 3 (bivalent dose).

Current CDC Covid-19 Vaccination Schedule

Children who are just beginning their 6 mo - 5 year old vaccines will choose one of those two pathways above.

All doses will be available immediately at the clinics below.

Questions: vaccinations@DocDashDFW.com
Clinic Location:

Pediatric Associates of Dallas

(Entrance is the 2nd floor of the parking ramp)

7859 Walnut Hl Ln #200, Dallas, TX 75230

Steps to register:

1. Complete this form for each person receiving a vaccination, and for each dose of vaccination you need. So a child receiving the Lil' Pfizer vaccination will need to complete this form three times, once for each dose in the series. The form serves as a consent to give each dose and this is a CDC requirement. It allows you to answer if there were any allergic reactions or concerns after each dose as well. We use the data from each clinic date chosen below to know how many of each vaccine to prepare the morning of the clinic. We appreciate the time it takes to do this, and apologize for the redundancy.

2. After submitting this form, you will be taken to a Sign Up Genius page to select a time slot on the day you registered for. This is a tool to help space clinic arrivals and minimize waiting times. Please select an open time slot. If you miss your time slot, you are fine, please come when you can.

If the Sign Up Genius is full on the date you registered for, simply skip this step. As a scheduling tool it has maximized its value. Arrive any time the clinic is open as we always vaccinate in the order of arrival. This process has worked well and wait times are very reasonable. So bottom line: do not change your registration date if the Sign Up Genius is full. We will have your vaccine ready to go.

As a reminder, Carpe Diem Health PLLC does not recieve your insurance information from Pediatric Associates of Dallas. Please take a moment and supply the information from your card below when your register.

There is no copay and nothing is billed to you / or due out of pocket for COVID19 vaccinations. Carpe Diem Health will bill your insurance for the shot administration fee.

If you do not have insurance at this time, please sign up for COVID vaccinations for you and your family at no cost. Simply leave the insurance boxes blank when you register your form(s).

3. You will receive an email after registering with the form information and your selected clinic date. You will receive a separate email from the Sign Up Genius software when/ if you choose a time slot.

4. You will receive a final email after your vaccination is complete, which will have a PDF attachment of your vaccine record for your files.

Vaccinations are registered with ImmTrac2, the Texas Immunization Registry.

Let us know if you have any feedback! We are always open to suggestions and ways to improve your experience.

Email:

Vaccinations@DocDashDFW.com

Medical questions or concerns to:

Dr.Chris@DocDashDFW.com

or leave a voicemail or a text message to (972) 846-9550.

Vaccinations administered by Carpe Diem Health PLLC, a Texas COVID-19 vaccination provider.
Which Pediatric Associates of Dallas vaccination clinic will you be attending? All Saturday clinic times are 09:00 to 12:00 (noon).

Saturday March 11thSaturday March 18thSaturday March 25th
Please select a COVID-19 vaccination.

Lil' PFIZER (6 mos - 4 years; 3 mcg dose) shot 1 of 3Lil' PFIZER (6 mos - 4 years; 3 mcg dose) shot 2 of 3 (at least 3 weeks following shot 1)Lil' PFIZER BIVALENT (6 mos - 4 years) shot 3 of 3 (at least 8 weeks following shot 2)Pediatric dose PFIZER (5 years through 11; 10 mcg dose) shot 1 of 2Pediatric dose PFIZER (5 years through 11; 10 mcg dose); shot 2 of 2 (at least 3 weeks later)PFIZER vaccination (12 years and up) shot 1PFIZER vaccination (12 years and up) shot 2 (at least 3 weeks later)PFIZER BIVALENT BOOSTER AGE 5 THROUGH 11 YEARS (at least 2 months from your last Pfizer or Moderna vaccination)PFIZER BIVALENT BOOSTER AGES 12 YEARS AND UP (at least 2 months from your last Pfizer or Moderna vaccination)Lil' Moderna (6 mos - 5 years; 25 mcg dose) shot 1 of 2Lil' Moderna (6 mos - 5 years; 25 mcg dose) shot 2 of 2 (at least 4 weeks later)Pediatric dose Moderna: shot 1 of 2 (age 6 years through 11; 50 mcg dose)Pediatric dose Moderna: shot 2 of 2 (age 6 years through 11; 50 mcg dose) (at least 4 weeks later)Moderna vaccination series (age 12 years and up) shot 1 of 2Moderna vaccination series (age 12 years and up, at least 28 days after shot 1) shot 2 of 2Lil’ MODERNA BIVALENT BOOSTER (6 months - 5 years); at least 8 weeks after completing doses 1 and 2 of the original Moderna vaccination seriesMODERNA BIVALENT BOOSTER (ages 6 years through 11)(25 mcg dose); at least 8 weeks after completing doses 1 and 2 of the original Moderna seriesMODERNA BIVALENT BOOSTER (12 years and up)(50 mcg dose)(after completing a primary COVID-19 vaccination series, and at least 8 weeks from your last COVID-19 vaccination)Novavax shot 1 (age 18 years and up only)Novavax shot 2 (at least 3 weeks later)
PATIENT INFORMATION
Vaccine recipient name*

First NameMiddle NameLast NameSuffix
Vaccine recipient address*

Street Address

Street Address Line 2

CityState Initials

Zip Code
Date of birth*

MonthDayYear
Gender at birth*
Race
Ethnicity
Vaccine recipient phone number (or Guardian if under 18)*
Vaccine recipient email (or Guardian if under 18)*
example@example.com
Emergency contact name*
Relationship to emergency contact*
Phone number of emergency contact*

PRE-VACCINATION QUESTIONS FOR REVIEW - TO BE COMPLETED BY VACCINE RECIPIENT, or ON BEHALF OF THE RECIPIENT BY THE GUARDIAN IF UNDER 18.*

	Yes	No
2. Have you ever received a dose of COVID-19 Vaccine?
3a. Have you ever had an allergic reaction to acomponent of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures?
3c. Have you ever had an allergic reaction to a previous dose of COVID-19 Vaccine?
4. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?
5. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a component of COVID-19 vaccine, polysorbate, or any vaccine or injectable medication? This would include food, pet, environmental, or oral medication allergies.

If this will be your second dose, or a booster dose of a COVID-19 vaccine, what was the date of your most recent vaccination?

MonthDayYear
INSURANCE STATUS. Please note we do not receive your insurance information from Pediatric Associates of Dallas. Thank you for completing this section for Carpe Diem Health PLLC. We will bill your insurance for the shot administration fee, with no copay or out of pocket charged to you. This is important as it will allow us to continue to provide this on-site service with PAD.

Primary Insurance Information

	Please Enter All Applicable Fields
Insurance Company
Member ID/ Insurance ID
Group Number

CONSENT FOR VACCINATION - To be completed by the vaccine recipient, or the Guardian if under 18 years of age

Check each box below after reading, and prior to signing the consent form.*

	Check each box
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet, a copy of which was provided to me upon completion of this Consent Form. (PDF Fact Sheet links for each manufacturer are provided below). I understand I will have the opportunity to ask questions at the time of my vaccination. 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 (the "Guardian").
I understand that at this time, the Pfizer BioNTech (5yo -11yo) and (12 and up) COVID-19 vaccines require a 2 dose series given at least 21 days apart, the Pfizer BioNTech (6 month through 4 year) series requires 3 doses, with dose two given at least three weeks after dose one, and dose three given at least eight weeks after dose two. All ages for the Moderna COVID-19 vaccine series require 2 doses given approximately 28 days apart. Novavax is a two dose series for COVID-19 vaccination. If this is my second dose, or a booster dose, I will bring my vaccine card or a photo or prior shot record if possible, to record my new vaccination and to verify dates.
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 a parent or legal guardian MUST be present for any minor to receive a COVID-19 vaccination.

Signature of consenting vaccine recipient, or the Guardian if under age 18.*

Clear
Full name of consenting Guardian for age < 18

First NameMiddle NameLast NameSuffix
Relationship to minor receiving vaccination

ParentLegal GuardianOther
Date Signed*

MonthDayYear
Date
Below are Patient Fact Sheets from each COVID-19 vaccine manufacturer. Please review the fact sheet associated with your scheduled vaccination.

If you have any questions, please ask at the time of your vaccine, or by voice message or text message to Carpe Diem Health PLLC (972) 846-9550 at any time. Email at Vaccinations@DocDashDFW.com

Pfizer-BioNTech COVID19 Vaccine Fact Sheet from 6 months through 4 years of age

Moderna COVID19 Fact Sheet for 6 months through 5 years of age

Pfizer-BioNTech COVID19 Vaccine Fact Sheet for 5 through 11 years of age

Moderna COVID19 Vaccine Fact Sheet age 6 through 11 years

Pfizer-BioNTech COVID-19 Vaccine Fact Sheet

Moderna COVID-19 Vaccine Fact Sheet

Novavax COVID-19 Vaccine Fact Sheet

Moderna BIVALENT BOOSTER Fact Sheet

Pfizer BioNTech BIVALENT BOOSTER Fact Sheet

When your vaccination is complete, you will receive the CDC COVID-19 Vaccination Record Card. If this is your 2nd or 3rd COVID-19 vaccination, please bring your CDC vaccination card and we will update it.

Submit your form using the link below. You will be taken to a SIGN ME UP GENIUS link from PAD, to select your desired arrival time slot. Participating with this SIGN ME UP GENIUS tool helps to minimize wait times for all on by spacing arrivals.

with Carpe Diem Health PLLC

COVID-19 Vaccine Registration and Consent Form