Burry's Pharmacy COVID-19 Vaccine Clinic- 04/15/2021

COVID-19 Vaccine Scheduling and Consent Form

Please read below carefully, fill out the form to the best of your knowledge. We will be providing the Janssen (Johnson & Johnson) COVID-19 vaccine. This is a single dose vaccine with no second dose needed. Beginning Monday, April 5th all Florida residents 18 years and older will be eligible to receive this vaccine.
Appointment*
Patient Demographic Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com (We will send a confirmation and reminder email here)
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Race*
Ethnicity *
Which arm would you like to receive your shot?*

Left armRight arm
I am a Florida resident with a valid Florida driver license or a copy of a valid Florida identification card that I will bring with me on the day of my appointment*

YesNo
State Surgeon General Scott Rivkees issued a Public Health Advisory on January 21 prioritizing vaccines for residents of the State of Florida or individuals in Florida for the purpose of providing health care services involving direct contact with patients.

To prove residency an adult resident must provide a copy of his or her valid Florida driver license or a copy of a valid Florida identification card.

Seasonal residents may provide a copy of two of the following the show proof of residential address:
1. A deed, mortgage, monthly mortgage statement, mortgage payment booklet or residential rental or lease agreement.
2. One proof of residential address from the season resident’s parent, step-parent or legal guardian or other person with whom the seasonal resident resides and a statement from the person with whom the seasonal resident resides stating that the seasonal resident does reside with him or her.
3. A utility hookup or work order dated within 60 days before registration.
4. A utility bill, not more than 2 months old.
5. Mail from a financial institution, including checking, savings, or investment account statements, not more than 2 months old.
6. Mail from a federal, state, county, or municipal government agency, not more than 2 months old.
Patient Prescription Insurance
Do you have health insurance?*

Yes, I DO have health insuranceNo, I DO NOT have health insurance (uninsured)
Rx BIN*
This information is found on your PRESCRIPTION insurance card
Rx PCN*
This information is found on your PRESCRIPTION insurance card
Rx GROUP ID*
This information is found on your PRESCRIPTION insurance card
Member ID*
This information is found on your PRESCRIPTION insurance card
Medicare Part B ID (If 65 years or older or have Part B coverage)
Red White & Blue Card
Emergency Contact Information
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Emergency Contact Relationship*
Vaccine Acknowledgement
The COVID-19 vaccine will reduce the risk of suffering from the new type of Coronavirus disease as known as COVID-19.

Please be aware that the vaccine is not completely effective like all other medicines. It can take a few weeks for your body to build up protection from the vaccine. There is always a chance of getting infected by Coronavirus even with the vaccine; however, the vaccine lessens the severity of any infection. A dose will reduce the chance of being seriously ill and reduce the risk of death due to Coronavirus.

This vaccine does not give you COVID-19 infection, but you still need to follow the health instructions in your workplace and in public areas, such as wearing a mask and keeping a distance from others.

The vaccine has some side effects as the other vaccines/medicines, but not everyone gets them.

The most likely side effects that you may experience from the vaccine:
- Fever
- Pain at the injection site
- Redness and hardness of the skin at the injection site
- Headache
- Muscle aches or pain
- Joint aches or pain
- Fatigue (tiredness)
- Nausea/vomiting
- Chills
- Underarm gland swelling on the side of vaccination
If you are currently pregnant or planning to get pregnant or your partner is planning to get pregnant; please see your doctor before getting vaccinated.

By signing this form I hereby accept that:
- I have read and understood the acknowledgment letter provided above.
- I declare that the information I have provided above is correct.
- I am giving my full consent to get the COVID-19 vaccine of my own will.
- This appointment CANNOT be rescheudled.
- I will show up ON TIME for my appointment.
- If I miss my appointment for any reason I will LOSE MY RESERVED COVID-19 VACCINE and will be required to wait until new apointments are available.
- I have been provided with the Vaccine Recipient Fact Sheet (https://www.fda.gov/media/146305/download)
- I have been provided with information about the CDC's V-safe After Vaccination Health Checker (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/vsafe.html )
Date of Form Completion*

MonthDayYear
Date
Signature*

Clear
Should be Empty:

COVID-19 Vaccine Scheduling and Consent Form

Patient Demographic Information

Patient Prescription Insurance

Emergency Contact Information

Vaccine Acknowledgement