COVID-19 & Flu Vaccine Screening Form

COVID-19 & Flu Vaccine Screening 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.
Select an appointment time*
Do you qualify to receive the COVID-19 Vaccine as per MD State Mandate and Guidance?*

YesNo (Fill out the form and join our wait list/standby) We will call contact you if available.Type option 3
Vaccine Recipient Name*

First NameMiddle NameLast Name
Vaccine Recipient Physical Address*

Street Address

Apt #

CityState Initials

Zip Code
Maryland County*
Date of Birth*

MonthDayYear
Gender at birth*
Race*
Ethnicity*
Email*
example@example.com
Vaccine Recipient Phone Number*

COVID-19 Vaccine Screen Questions*

	Yes	No
1. Are you feeling sick today?
2. Have you ever felt dizzy or faint before, during or after a shot?
3a. Have you ever had an allergic reaction to acomponent of the COVID-19 and flu vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures?
3b. Have you ever had an allergic reaction to Polysorbate?
3c. Have you ever had an allergic reaction to a previous dose of COVID-19 Vaccine?
4. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?
5. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a component of COVID-19 vaccine, polysorbate, or any vaccine or injectable medication? This would include food, pet, environmental, or oral medication allergies.
6. Are you pregnant or plan to become pregnant or breastfeeding?
7. Have you received hematopoietic cell transplant (HCT) or CAR-T cell therapies since receiving COVID-19 vaccine?
8. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? [note: monoclonal antibodies does not include antibiotics that you would be prescribed and filled at a pharmacy]
9. Do you have a weakened immune system caused by something such as HIV infection or cancer or had Guillain-Barre-syndrome or do you take immunosuppressive drugs or therapies?
10. Do you have a bleeding disorder or are you taking a blood thinner?
11. Do you have a history of myocarditis or pericarditis?

Allergic Reaction Defined: This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.
Which arm would you like to get the injection on*

Left ArmRight Arm
Vaccine Manufacturer

Comirnaty Age 12 and Up (Pfizer)Spikevax Age 12 and Up (Moderna)Pediatric Moderna Age 3 and Up
Vaccine*

Covid & Flu VaccineCovid VaccineFlu Vaccine

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

	Check each box
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet (the Pfizer/Moderna Fact Sheet is available after clicking submit), a copy of which I was provided with this Consent Form. 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 is now commercial vaccine. I will bring my insurance card with me at the time of appointment. I give consent to receive text messages regarding immunization service.
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 that if my insurance rejects, for any reason I will be billed for vaccine and administration cost for Covid commerical vaccine. I authorize to bill up to eight covid test kits to insurance for my personal use.

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 Pharmacy Insurance Card *

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 Document

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
Immunizer Name
First and Last Name
Immunizer Signature

Clear
Lot Number
Expiration Date:
Pharmacy Name
Pharmacy NPI*
Should be Empty: