COVID Vaccine Consent Form

Section I. Appointment Scheduler

Please pick a day and time for your vaccination *

Section II. Personal Information

Patient's Name: *

First Name Last Name

Date of Birth: *

Age: *

Must be over 18

Address: *

Street Address Line 2

State *

Phone Number: *

Email *

Gender: *

M F

Are you over the Age of 18? *

Yes No (J & J Vaccine is only approved for age 18 & over. We cannot vaccinate you with this vaccine if you are not over the age of 18)

Race: *

African American American Indian Asian Caucasian/White Hispanic or Latino Native Hawaiian/Other Pacific Islander Prefer not to answer

What dose of COVID-19 vaccine will this be?

First Dose Booster Dose

Section III. Questionnaire for Immunization

Please select the correct option below: *

	Yes	No	Don't know or N/A
COVID-19 Screening Questions: In the past two weeks, have you tested positive for COVID-19 or are you currently being monitored for COVID-19?
In the past two weeks, have you had a known exposure with anyone who tested positive for COVID-19?
Have you had a new onset of fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, nausea, vomiting, or diarrhea?
Questionnaire for Immunization: The manufacturer advises against administration of Janssen COVID-19 Vaccine to individuals with known history of a severe allergic reaction (e.g. anaphylaxis) to any component of the Vaccine. The Janssen COVID-19 Vaccine contains the following ingredients: citric acid monohydrate, trisodium citrate dihydrate, ethanol, 2-hydroxypropyl β-cyclodextrin (HBCD), polysorbate-80, sodium chloride. Each dose may also contain residual amounts of host cell proteins and/or host cell DNA. 1. Do you have a history of allergic reaction to any of these ingredients listed above?
2. Do you have a history of severe allergic reactions, such as an immediate-onset anaphylaxis to medications, foods, or any vaccines (eggs, gelatin, thimerosal, neomycin, gentamicin, latex, aluminum, preservatives, baker's yeast, etc.)?
3. Have you ever been diagnosed with Guillain-Barre’ syndrome or other neurological disorder related to a vaccine?
4. Have you received any vaccine (flu, pneumococcal, shingles, etc.) within the last 14 days?
5. For women: Are you pregnant or is there a chance you could become pregnant during the next month?
6. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19 in the last 90 days?

Please specify the allergy from Q2:

Section IV. Signatures

I have read, or have had read to me, the written information regarding the vaccine(s) being administered. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s) being administered and have received a copy of a current FACT SHEET FOR RECIPIENTS AND CAREGIVERS - EMERGENCY USE AUTHORIZATION (EUA) OF THE JANSSEN COVID-19 VACCINE TO PREVENT CORONAVIRUS DISEASE 2019 (COVID-19) IN INDIVIDUALS 18 YEARS OF AGE AND OLDER. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless West End Pharmacy, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s). I authorize West End Pharmacy to bill either my insurance or HRSA (if no insurance) for the administration fee of the vaccine. West End Pharmacy may utilize my information provided above to look up my insurance eligibility information. I understand the vaccine will be provided to me at no charge. I certify that I am at least 18 years old and hereby give my consent to the pharmacists of this West End Pharamcy to administer the vaccine(s). If under 18 years old signature by parent or guardian is required.
I agree to wait near the vaccination location for approximately 15 minutes for observation by the pharmacist.

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

Use mouse/mouse-pad to Click and Draw Clear

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: *

Use Mouse to Click and Draw Clear

Pharmacist Use Only:

Vaccine Name:		Manf.	LOT	Exp Date	Dose	Site of Injection	Date of EUA/FS	RPH Initials
Janssen Covid-19 Vaccine		J&J	1822811	03/20/2022	0.5 ml	LD RD	12/2020

Vaccine Card: Date Adminstered:

GRITS:

By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.

Janssen (J&J) COVID-19 Vaccine Consent Form