HealthRx COVID-19 Vaccine Screening Form

COVID-19 Vaccine Consent Form

In order to receive the vaccine, you must be in the most appropriate phase of the vaccine rollout. Visit this link (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations.html) for more information at the federal level. States may have a different approach.
Is the Patient at least 6 months old in order to receive the Pfizer vaccine or at least 12 years old in order to receive the Moderna?*

YesNo
Which COVID-19 Vaccine Would you like?*

PFIZER FIRST DOSE (12YRS OR OLDER)PFIZER SECOND DOSE (12YRS OR OLDER)PFIZER THRID DOSE (12YRS OR OLDER)PFIZER BIVALENT BOOSTER (12YRS OR OLDERPEDIATRIC PFIZER FIRST DOSE (5YRS TO 11YRS)PEDIATRIC PFIZER SECOND DOSE (5YRS TO 11YRS)PEDIATRIC PFIZER BOOTER (5YRS TO 11YRS)MODERNA FIRST DOSE (18YRS OR OLDER)MODERNA SECOND DOSE (18YRS OR OLDER)MODERNA THIRD DOSE (18YRS OR OLDER, DOSE IS 0.5ML)MODERNA BIVALENT BOOSTER (12YRS OR OLDER, DOSE IS 0.5ML)ADOLESCENT PFIZER FIRST DOSE (6MONTHS TO UNDER 5YRS)ADOLESCENT PFIZER SECOND DOSE (6MONTHS TO UNDER 5YRS)
Date of First Dose

MonthDay Year
Date
What date did you receive your Second Dose OR Last Booster?

MonthDay Year
Date
Select an appointment time*
Vaccine Recipient Name*

First Name Middle Name Last Name
Vaccine Recipient Physical Address*

Street Address

Apt #

City State Initials

Zip Code
Date of Birth*

MonthDay Year
Gender at birth*
Race*
Ethnicity*
Vaccine Recipient Phone Number*
Mother's Maiden Name*
Required for proper vaccine documentation
Email*
example@example.com

COVID-19 Vaccine Screen Questions*

	Yes	No
1. Are you feeling sick today?
2. In the last 10 days, have you had a COVID-19 test because you had symptoms and are still awaiting your test results or been told by a health care provider or health department to isolate or quarantine at home due to COVID-19 infection or exposure?
3. Have you been treated with antibody therapy or convalescent plasma for COVID-19 in the past 90 days (3 months)?
4. Have you ever had an immediate allergic reaction (e.g. hives, facial swelling, difficulty breathing, anaphylaxis) to any vaccine, injection, or shot or to any component of the COVID-19 vaccine, or a severe allergic reaction (anaphylaxis) to anything?
5. Are you pregnant or considering becoming pregnant?
6. Do you have cancer, leukemia, HIV/AIDS or any other condition that weakens the immune system?
7. Do you have a bleeding disorder, a history of blood clots or are you taking a blood thinner?
8. Do you have a history of myocarditis (inflammation of the heart muscle) or pericarditis (inflammation of the lining around the heart)?
9. Do you have a history of MIS-C or MIS-A (multisystem inflammatory syndrome in children or multisystem inflammatory syndrome in adults)?
10. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
11. Do you have a bleeding disorder or are you taking a blood thinner?
12.Are you 5-11 yrs old and have received 2 doses of the Pediatric Pfizer Vaccine, the second dose being 5 months ago?
13. Have you received aprevious dose of a non-FDA authorized or approved COVID-19vaccine authorized by the WHO1 but not by the FDA (AstraZeneca – VAXZEVRIA, Sinovac –CORONAVAC, SerumInstitute of India – COVISHIELD, Sinopharm/BIBP, COVAXIN, Nuvaxovid, or CanSino Biologics – Convidecia)?
14. Do you take any medications that affect your immune system, such as cortisone, prednisone or other steroids, anticancer drugs, or have you had any radiation treatments?
15. Are you 12yrs or older and have you received 2 doses of the Pfizer or Moderna vaccine, the second dose or last booster being at least 2 months ago? ?
16. Have you received a previous dose of the Janssen (Johnson & Johnson), at lease 2 months ago
17. If you had a previous dose of Janssen (Johnson & Johnson), did you develop thrombosis with thrombocytopenia syndrome (TTS)?

Which arm would you like to get the injection on*

Left ArmRight Arm

Consent (check each box below after reading and prior to signing the form)*

	Check each box
Emergency Use Authorization 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 I was provided. Emergency Use Authorization. The FDA has made the COVID-19 vaccine available under an emergency use authorization (EUA). The EUA is used when circumstances exist to justify the emergency use of drugs and biological products during an emergency, such as the COVID-19 pandemic. This vaccine has not undergone the same type of review as an FDA-approved or cleared product. However, the FDA’s decision to make the vaccine available is based on the totality of scientific evidence available, showing that known and potential benefits of the vaccine outweigh the known and potential risks. Please note: FDA approved the Pfizer-BioNTech COVID-19 vaccine as a two-dose series in individuals 16 years of age and older. The vaccine continues to be available under an EUA for certain populations, including for those individuals 5 through 15 years of age and for the administration of a third dose in the populations set forth in the consent section below. Consent I have read, or had explained to me, the information sheet about the COVID-19 vaccination. I understand that if my vaccine requires two doses, I will need to be administered (given) two doses to be considered fully vaccinated. Further, I understand that a booster dose of COVID-19 vaccine may be recommended at least 2 months following the first dose of Janssen vaccine or at least 6 months following the second dose of PfizerBioNTech or Moderna COVID-19 vaccine if I am a member of a certain population (e.g., 65 years or older, 18 years old or older and a resident of a long term care facility, 50-64 years with an underlying medical condition, 18-49 years old with an underlying medical condition based on individual benefits and risks, 18-64 years old and at an increased risk for COVID-19 exposure and transmission because of working or living in a high-risk setting and based on individual benefits and risks) to increase my protection. I have had a chance to ask questions which were answered to my satisfaction (and ensured the person named above for whom I am authorized to provide surrogate consent was also given a chance to ask questions). I understand the benefits and risks of the vaccination as described. I request that the COVID-19 vaccination be given to me (or the person named above for whom I am authorized to make this request and provide surrogate consent). I authorize release of all information needed (including but not limited to medical records, copies of claims and itemized bills) to verify payment and as needed for other public health purposes, including reporting to applicable vaccine registries. 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 may require 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 there will be no cost to me for this vaccine. I understand that any monies or benefits for administering the vaccine will be assigned and transferred to the vaccinating provider, including benefits/monies from my health plan, Medicare or other third parties who are financially responsible for my medical care.

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.
Please Upload Insurance Card

function SvgDhtupload(props) { return /* @__PURE__ */ react.createElement("svg", dhtupload_svg_extends({ width: 54, height: 47, xmlns: "http://www.w3.org/2000/svg" }, props), dhtupload_svg_path || (dhtupload_svg_path = /* @__PURE__ */ react.createElement("path", { d: "M40.213 10.172c1.897.21 3.68.738 5.35 1.58a15.748 15.748 0 014.374 3.242 15.065 15.065 0 012.951 4.533c.72 1.704 1.08 3.522 1.08 5.455 0 1.827-.28 3.654-.843 5.48-.562 1.828-1.379 3.47-2.45 4.929A13.39 13.39 0 0146.669 39c-1.599.948-3.452 1.458-5.56 1.528H37.26a1.62 1.62 0 01-1.185-.5 1.62 1.62 0 01-.501-1.186c0-.457.167-.852.5-1.186.334-.334.73-.5 1.186-.5h3.848c1.44 0 2.75-.37 3.926-1.108a10.851 10.851 0 003.03-2.846 13.53 13.53 0 001.95-3.9 14.23 14.23 0 00.686-4.321c0-1.582-.316-3.066-.949-4.454a11.623 11.623 0 00-2.582-3.636 12.857 12.857 0 00-3.742-2.478 11.054 11.054 0 00-4.48-.922l-1.212-.053-.37-1.159c-.878-2.81-2.292-4.998-4.242-6.562-1.95-1.563-4.594-2.345-7.932-2.345-2.108 0-4.005.36-5.692 1.08-1.686.72-3.136 1.722-4.348 3.005-1.212 1.282-2.143 2.81-2.793 4.585-.65 1.774-.975 3.68-.975 5.718h.053l.105 1.581-1.528.264c-1.863.316-3.444 1.317-4.744 3.004-1.3 1.686-1.95 3.584-1.95 5.692 0 2.39.8 4.462 2.398 6.219 1.599 1.757 3.488 2.635 5.666 2.635h4.849c.492 0 .896.167 1.212.5.316.335.474.73.474 1.187 0 .456-.158.852-.474 1.185-.316.334-.72.501-1.212.501h-4.849a10.08 10.08 0 01-4.374-.975 11.673 11.673 0 01-3.61-2.661 13.173 13.173 0 01-2.478-3.9A12.073 12.073 0 010 28.301c0-2.706.755-5.148 2.266-7.326 1.511-2.178 3.444-3.636 5.798-4.374.14-2.354.658-4.542 1.554-6.562.896-2.02 2.091-3.777 3.584-5.27 1.494-1.494 3.25-2.662 5.27-3.505C20.493.422 22.733 0 25.193 0c1.898 0 3.637.237 5.218.711 1.581.475 3.004 1.151 4.269 2.03a13.518 13.518 0 013.268 3.215 18.628 18.628 0 012.266 4.216zm-11.964 13.44l6.22 6.85c.245.247.368.537.368.87 0 .334-.123.642-.369.923l-.421.263c-.211.246-.484.343-.817.29a1.544 1.544 0 01-.87-.448l-3.69-4.11v16.97c0 .492-.166.896-.5 1.212-.334.316-.729.474-1.186.474-.492 0-.896-.158-1.212-.474-.316-.316-.474-.72-.474-1.212V28.25l-3.584 4.005a1.544 1.544 0 01-.87.448.959.959 0 01-.87-.29l-.42-.264c-.247-.28-.37-.588-.37-.922 0-.334.123-.624.37-.87l6.113-6.746v-.052l.421-.422a.804.804 0 01.396-.29c.158-.053.307-.079.448-.079.175 0 .333.026.474.079.14.053.281.15.422.29l.421.422v.052z", fill: "none" }))); }

Cancelof
For uninsured patients, please select at least one of the following that you will bring with you to your appointment.

Social Security NumberState identification number and state of issuanceDriver's license number and state of issuance
Please Upload Supporting Uninsured Document

function SvgDhtupload(props) { return /* @__PURE__ */ react.createElement("svg", dhtupload_svg_extends({ width: 54, height: 47, xmlns: "http://www.w3.org/2000/svg" }, props), dhtupload_svg_path || (dhtupload_svg_path = /* @__PURE__ */ react.createElement("path", { d: "M40.213 10.172c1.897.21 3.68.738 5.35 1.58a15.748 15.748 0 014.374 3.242 15.065 15.065 0 012.951 4.533c.72 1.704 1.08 3.522 1.08 5.455 0 1.827-.28 3.654-.843 5.48-.562 1.828-1.379 3.47-2.45 4.929A13.39 13.39 0 0146.669 39c-1.599.948-3.452 1.458-5.56 1.528H37.26a1.62 1.62 0 01-1.185-.5 1.62 1.62 0 01-.501-1.186c0-.457.167-.852.5-1.186.334-.334.73-.5 1.186-.5h3.848c1.44 0 2.75-.37 3.926-1.108a10.851 10.851 0 003.03-2.846 13.53 13.53 0 001.95-3.9 14.23 14.23 0 00.686-4.321c0-1.582-.316-3.066-.949-4.454a11.623 11.623 0 00-2.582-3.636 12.857 12.857 0 00-3.742-2.478 11.054 11.054 0 00-4.48-.922l-1.212-.053-.37-1.159c-.878-2.81-2.292-4.998-4.242-6.562-1.95-1.563-4.594-2.345-7.932-2.345-2.108 0-4.005.36-5.692 1.08-1.686.72-3.136 1.722-4.348 3.005-1.212 1.282-2.143 2.81-2.793 4.585-.65 1.774-.975 3.68-.975 5.718h.053l.105 1.581-1.528.264c-1.863.316-3.444 1.317-4.744 3.004-1.3 1.686-1.95 3.584-1.95 5.692 0 2.39.8 4.462 2.398 6.219 1.599 1.757 3.488 2.635 5.666 2.635h4.849c.492 0 .896.167 1.212.5.316.335.474.73.474 1.187 0 .456-.158.852-.474 1.185-.316.334-.72.501-1.212.501h-4.849a10.08 10.08 0 01-4.374-.975 11.673 11.673 0 01-3.61-2.661 13.173 13.173 0 01-2.478-3.9A12.073 12.073 0 010 28.301c0-2.706.755-5.148 2.266-7.326 1.511-2.178 3.444-3.636 5.798-4.374.14-2.354.658-4.542 1.554-6.562.896-2.02 2.091-3.777 3.584-5.27 1.494-1.494 3.25-2.662 5.27-3.505C20.493.422 22.733 0 25.193 0c1.898 0 3.637.237 5.218.711 1.581.475 3.004 1.151 4.269 2.03a13.518 13.518 0 013.268 3.215 18.628 18.628 0 012.266 4.216zm-11.964 13.44l6.22 6.85c.245.247.368.537.368.87 0 .334-.123.642-.369.923l-.421.263c-.211.246-.484.343-.817.29a1.544 1.544 0 01-.87-.448l-3.69-4.11v16.97c0 .492-.166.896-.5 1.212-.334.316-.729.474-1.186.474-.492 0-.896-.158-1.212-.474-.316-.316-.474-.72-.474-1.212V28.25l-3.584 4.005a1.544 1.544 0 01-.87.448.959.959 0 01-.87-.29l-.42-.264c-.247-.28-.37-.588-.37-.922 0-.334.123-.624.37-.87l6.113-6.746v-.052l.421-.422a.804.804 0 01.396-.29c.158-.053.307-.079.448-.079.175 0 .333.026.474.079.14.053.281.15.422.29l.421.422v.052z", fill: "none" }))); }

Cancelof
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):*

Clear
Date Signed*

MonthDay Year
Date
Pharmacist Name
First and Last Name
Pharmacist Signature

Clear
Immunizer Name
First and Last Name
Immunizer Signature

Clear
Lot Number
Expiration Date:
Vaccine Manufacturer

Moderna VaccinePfizer Vaccine
Pharmacy Name
Pharmacy NPI*
Should be Empty:

COVID-19 Vaccine Consent Form