HealthRx COVID-19 Vaccine Screening Form

Is the Patient at least 5 years old in order to receive the Pfizer vaccine or at least 18 years old in order to receive the Moderna? *

Yes No

Which COVID-19 Vaccine Would you like? *

PFIZER FIRST DOSE (12YRS OR OLDER) PFIZER SECOND DOSE (12YRS OR OLDER) PFIZER BOOSTER OR THRID DOSE (18YRS OR OLDER) PEDIATRIC PFIZER FIRST DOSE ( 5YRS TO 11YRS) PEDIATRIC PFIZER SECOND DOSE ( 5YRS TO 11YRS) MODERNA FIRST DOSE (18YRS OR OLDER) MODERNA SECOND DOSE (18YRS OR OLDER) MODERNA THIRD DOSE (18YRS OR OLDER) MODERNA BOOSTER (18YRS OR OLDER)

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 *

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. Are you 65 years old or older?
10. Are you 18 years old or older AND a resident of a long-term care facility?
9. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
10. Do you have a bleeding disorder or are you taking a blood thinner?
11. Are you 50 through 64 years old AND have one or more of the following conditions (due to increased risk of moderate or severe illness or death from the virus that causes COVID-19): 1.) Cancer (current or in remission, including 9/11-related cancers); 2.) Chronic kidney disease; 3.) Pulmonary Disease, limited to, COPD (chronic obstructive pulmonary disease), asthma (moderate-to-severe), pulmonary fibrosis, cystic fibrosis, tuberculosis, and 9/11 related pulmonary diseases; 4.) Intellectual and Developmental Disabilities including Down Syndrome; 5.) Heart conditions, including but not limited to heart failure, coronary artery disease, cardiomyopathies, or hypertension (high blood pressure); 6.) Immunocompromised state (weakened immune system) including but not limited to solid organ transplant or from blood or bone marrow transplant, immune deficiencies, HIV, use of corticosteroids, use of other immune weakening medicines, or other causes; 7.) Severe Obesity (BMI 40 kg/m2 or higher), Obesity (body mass index [BMI] of 30 kg/m2 or higher but < 40 kg/m2), Overweight (BMI of 25 kg/m2 or higher but < 30kg/m2); 8.) Pregnant or recently pregnant; 9.) Sickle cell disease or Thalassemia; 10.) Type 1 or 2 diabetes mellitus; 11.) Cerebrovascular disease (affects blood vessels and blood supply to the brain); 12.) Neurologic conditions including but not limited to Alzheimer's Disease or dementia; 13.) Liver disease limited to cirrhosis, non-alcoholic fatty liver disease, alcoholic liver disease, or autoimmune hepatitis; 14.) Current or former smoker; 15.) Substance use disorder, 16) Mental health disorders limited to mood disorders including depression, schizophrenia spectrum disorders.
12. Are you 18 through 49 years old AND have one or more of the underlying medical conditions listed above, and are seeking a booster because the benefits outweigh the risks or are you at increased risk for COVID-19 exposure and transmission because of working or living at a high-risk setting?
13. 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?
14. Have you received 2 doses of the Pfizer or Moderna vaccine, the second dose being at least 6 months ago?
15. Have you received a previous dose of the Janssen (Johnson & Johnson), at lease 2 months ago
16. 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 Arm Right 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

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

Social Security Number State identification number and state of issuance Driver's license number and state of issuance

Please Upload Supporting Uninsured Document

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

Clear

Date Signed *

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 Vaccine Pfizer Vaccine

Pharmacy Name

Pharmacy NPI *

DATE OF YOUR 2ND DOSE IF YOU ARE GETTING THE BOOSTER/THIRD DOSE This is a fill in the blanks field. Please add appropriate blank fields and text.

COVID-19 Vaccine Consent Form