Pediatric Pfizer COVID-19 INFORMED CONSENT FORM ; 5-11 YEARS OLD

Name*

First NameLast Name

Email*

example@example.com

Phone*

Address*

Address

Street Address Line 2

CityState

Zip Code

Sex as identified on insurance*

Date of Birth*

Date

Age*

Mother's Maiden Name*

Required for proper vaccine documentation

Ethnicity*

Race*

Primary Care Doctor*

Primary Care Doctor City/State*

Emergency Contact*

Relationship to Emergency Contact*

Emergency Contact Phone*

Which dose of COVID-19 vaccine will this be?*

FirstSecond

If Second, Date of First Dose*

Date

Which vaccine did you receive?*

PfizerModernaJanssenOther

At this time we are only able to provide Pfizer vaccinations.

INSURANCE INFORMATION:*

MedicaidMedicare Part BPrivate InsuranceNo Insurance

Medicaid: Provider*

Policy/Member ID #*

Medicaid #*

Rx Group #*

Subscriber ID #*

Responsible Party*

Policy Holder’s Date of Birth*

Date

Private Insurance: Insurer*

Subscriber ID*

Rx Bin #*

PCN*

Rx Group #*

To have your vaccine administration fee paid for by the United States Health Resources & Services Administration’s COVID-19 Program for uninsured patients, please provide one of the following.*

Social Security NumberState Identification NumberDriver's License Number

Social Security #*

State Identification #*

State of Issuance*

Driver's License #*

State of Issuance*

I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA), 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, an individual for whom I represent and for whom I am authorized to sign this Consent and Release.

If guarantor/guardian, indicate your relationship to the recipient

Signature*

Printed Name (patient or guarantor/guardian)*

Date of Signature*

Date

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*

Screening Questionnaire*

	Yes	No	Don't Know
Are you feeling sick today?
Have you ever had an allergic reaction to a component of a COVID-19 vaccine including Polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures? *
Have you ever had an allergic reaction to a component of a COVID-19 vaccine including Polysorbate, which is found in some vaccines, film coated tablets, and intravenous steroids? *
Have you ever had an allergic reaction to a previous dose of COVID-19 vaccine? *
Have you ever had an allergic reaction to a vaccine or injectable therapy that contains multiple components, one of which is a COVID-19 vaccine component, but it is not known which component elicited the immediate reaction? *
Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication? *
Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a component of COVID-19 vaccine, or any vaccine or injectable medication? This would include food, pet, venom, environmental, or oral medication allergies?
Have you received any vaccine in the last 14 days?
Have you ever had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?
Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?
Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
Do you have a bleeding disorder or are you taking a blood thinner?
Do you have a history of or a risk factor for a blood clotting disorder?
Are you pregnant or breastfeeding?
Do you have dermal fillers?

*This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to thehospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.

Please explain any “Yes” answers provided above*

If you need to reschedule your appointment after submitting this form, please do not fill out a second form, but rather call the pharmacy to reschedule.

Appointment*

PFIZER COVID-19 INFORMED CONSENT FORM- first and second dose

PATIENT INFORMATION