COVID Vaccine Consent Form

COVID Vaccine Consent Form

* Please fill out the required details below
This form is for Moderna immunizations only

If you have any remaining questions,

please call us at (319) 393-3210

There are NO Moderna immunizations

available at our pharmacy!

Please check back on Tuesday 4/13/21

for availability on Thursday!

Are you one of the following? *

Age 65 and Older Age 18-64 with qualifying chronic diseases states Age 18-64 without chronic disease states

Section III. Appointment Scheduler
**Vaccine supply is limited. Please keep your appointment or call if you need to cancel or change it. Additionally, due to vaccine requirements; we may call you to see if you can come earlier or later. If you miss an appointment, no doses will be held to guarantee your dose.**
Please pick a day and time for your vaccination *

Section IV. Signatures

I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) (EUA | Moderna COVID-19 Vaccine), a copy of which I was provided with this Consent and Release. 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 and Release.
Signature of Person to Receive Vaccine & EUA/VIS (or Signature of Parent/Guardian if Patient is < 18 yo) *

Clear
I have received a copy of the notice of Privacy Practices. I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.
Signature of Acknowledgment of Notice of Privacy Practices: *

Clear
Check one of the boxes below that attest the following information is true and accurate:

I do have insurance and it is already on file at Clark's Pharmacy or will be provided by uploading a picture file of it or at the time of immunization I do not have any insurance, including but not limited to Medicare, Medicaid or any other private or government-funded health benefit plan
In order to have your vaccine administration fee paid for by the United States Health Resources & Services Administration's COVID-19 Program for uninsured patients, please select to provide one of the following: *

Social Security Number State identification number and state of issuance Driver's license number and state of issuance Provide at appointment
Social Security Number *
State identification number and state of issuance *
Driver's license number and state of issuance *
Please take or upload pictures of front & back of insurance card for billing purposes

Cancel of
I authorize the pharmacy to bill my insurance on my behalf for the immunization
By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.
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