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 12 Years or older in order to receive the Pfizer or Moderna 2023-2024 vaccine?*

YesNo
Which COVID-19 Vaccine Would you like?*

PFIZER COMIRNATY MRNA 2023-2024 VACCINE (12YRS OR OLDER)MODERNA SPIKEVAX MRNA 2023-2024 VACCINE (12 YEARS AND OLDER)
What date did you receive your Second Dose OR Last Booster?

MonthDayYear
Date
Select an appointment time*
Vaccine Recipient Name*

First NameMiddle NameLast Name
Vaccine Recipient Physical Address*

Street Address

Apt #

CityState Initials

Zip Code
Date of Birth*

MonthDayYear
Gender at birth*
Race*
Ethnicity*
Vaccine Recipient Phone Number*
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?
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?
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. Are you moderately or severely immunocompromised due to 1 or more of the medical conditions or receipt of immunosuppressive medications or treatments listed below? 1)Active treatment for a solid tumor 2)hematologic malignancies 3)Receipt of a CAR-T cell or hematopoletic stem cell transplant (within 2yrs of transplantation or taking immunosuppression therapy) 5) Moderate or severe primary immunodeficiency (e.g, Digeorge syndrome, Wiskott-Aldrich syndrome), 6)advanced or untreated HIV infection, 7)Active treatment with High dose Corticosteroids, (eg 20mg prednisone or equivalent/day), alkylating agents, antimetabolites, transplant related immunosuppressive drugs, cancer chemo agents classified as TNF blockers, and other biologic agents that are immunosuppressive or immunomodulatory.
11. Do you have a bleeding disorder or are you taking a blood thinner?
12.Have you recently received and orthopoxvirus vaccine within the last 4 weeks (e.g., JYNNEOS or ACAM2000)??

How old will the person be on the day of vaccination? *
Has the person to be vaccinated ever received a dose of COVID-19 vaccine? If yes, which product was administered?*

NonePfizer-Bio TechModernaJanssen (johnson & johnson)NovavaxOther
How may doses of COVID-19 vaccine were previously administered?
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.

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

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

Clear
Date Signed*

MonthDayYear
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*
Is there a Health Rx Employee that Referred you to the vaccine?*
Should be Empty:

COVID-19 Vaccine Consent Form