Hague Pharmacy Johnson & Johnson COVID-19 Vaccine Appointment Scheduling and Consent Form

IF YOU MISSED YOUR SECOND DOSE PFIZER COVID-19 VACCINATION. YOU CAN VISIT ONE OF THE FOLLOWING LOCATIONS IN NORFOLK AND CHESAPEAKE THIS WEEKEND TO GET YOUR SHOT BETWEEN 12PM - 5PM

04/10/21 SATURDAY

HINDU TEMPLE OF HAMPTON ROADS

217 SAMPSON CREEK ROAD, CHESAPEAKE, VA

04/11/2021 SUNDAY

FIRST BAPTIST CHURCH BERKLEY

706 WEST BERKLEY AVE, NORFOLK,VA

YOU DO NOT HAVE TO FILL THIS OUT FOR SECOND SHOTS IF YOU RECEIVED YOUR FIRST SHOT THROUGH HAGUE PHARMACY
601 Children's Lane, Norfolk, VA 23507
JOHNSON & JOHNSON VACCINE ONLY SINGLE DOSE
PLEASE SELECT THE VACCINE YOU ARE GETTING - JOHNSON & JOHNSON ONLY FOR 04/10/2021*
Please only proceed if you fall under the current VIRGINIA Phase 1A & 1B*

Healthcare WorkerPatient 65 years or olderPersons Age 18 - 64 with at least one high risk medical condition that the patient self-attests. Conditions listed are: Cancer, Chronic kidney disease, COPD (chronic obstructive pulmonary disease), Down Syndrome, Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies; Immunocompromised state (weakened immune system) from solid organ transplant; Obesity (body mass index [BMI] of 30 kg/m2 or higher but < 40 kg/m2); Severe Obesity (BMI ≥ 40 kg/m2); Pregnancy; Sickle cell disease; Smoking; Type 2 diabetes mellitusVirginia Phase 1B
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.
Please Select an appointment time! *
Vaccine Recipient Name*

FirstNameMiddle NameLastName
Email*
example@example.com
Vaccine Recipient Physical Address*

Street Address

CityState Initials

Zip Code
Date of Birth*

MonthDayYear
Gender at birth*
Race*
Ethnicity*
Vaccine Recipient Phone Number*
Mother's Maiden Name*
Required for proper vaccine documentation
Primary Care Provider Name
Emergency Contact Name*
Relationship to Emergency Contact*
Phone Number of Emergency Contact*

COVID-19 Vaccine Screen Questions*

	Yes	No
1. Are you feeling sick today?
2. Have you ever received a dose of COVID-19 Vaccine?
3a. Have you ever had an allergic reaction to acomponent of the COVID-19 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. Have you received any vaccine in the last 14 days?
7. Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19?
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 do you take immunosuppressive drugs or therapies?
10. Do you have a bleeding disorder or are you taking a blood thinner?
11. Are you pregnant or breastfeeding?

COVID-19 Vaccine Manufacturer for the first dose received (do not complete if you selected "no" to #2 above.
Required if you selected "Yes" to #2
Date of first dose (do not complete if you selected "no" to #2 above.)

MonthDayYear
Required if you selected "Yes" to #2

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/J&J 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, some COVID-19 vaccine requires 2 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 that I will be receiving the vaccination at no cost to me.
On Behalf of myself, my heirs and personal representatives, I hereby release and hold harmless Hague Pharmacy at CHKD, and their staff, associates, successors, affiliates, subsidiaries, officers, directors, contractors, and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the vaccine listed above.

The vaccine is available to anyone no matter if insured or uninsured. Please check only one of the following.*

	Check one
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.

What insurance do you have? If no insurance please select uninsured. *
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 take a Picture of your Driver License, Medicare Red White & Blue Card, and Insurance Card and Upload *

Cancelof

VACCINE CLINIC LOCATION FOR SATURDAY *

	Please acknowledge
HINDU TEMPLE OF HAMPTON ROADS 217 SAMPSON CREEK ROAD, CHESAPEAKE, VA

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

Clear
Date Signed

MonthDayYear
Date

Pharmacy Use Only

	1st Dose	2nd Dose	IM LEFT	IM Right
Pfizer Vaccine
Moderna Vaccine
Johnson & Johnson

Pharmacy Use Only - Date Shot Administered

MonthDayYear
Pharmacist Name
Signature

Clear
Should be Empty:

601 Children's Lane, Norfolk, VA 23507

JOHNSON & JOHNSON VACCINE ONLY SINGLE DOSE

COVID-19 Vaccine Consent Form