Christian Brothers Academy Clinic Covid Registration & Consent January 12th (8AM-10AM)
In order to receive the vaccine, you must be in the most appropriate phase of the vaccine rollout. Visit this link (https://covid19.nj.gov/faqs/nj-information/slowing-the-spread/who-is-eligible-for-vaccination-in-new-jersey-who-is-included-in-the-vaccination-phases#direct-link) for more information at the federal level. States may have a different approach.
Are you at least 5 years of age/ qualified to get vaccination under NJ's Vaccination Plan as of today's date?.
*
Yes
No
Select an appointment time (If you do not see an available time, that means we are fully booked for that day, please check back the next day.) IF YOU DO NOT SELECT AN APPOINTMENT TIME, IT DOES NOT GUARANTEE YOU WILL RECEIVE A VACCINE.
Which Covid 19 Vaccine would you like to register for?
*
Pfizer Pediatric Dose (Ages 5-11/1st or 2nd Dose)
Pfizer 1st Dose
Pfizer 2nd Dose
Pfizer Booster
Moderna 1st Dose
Moderna 2nd Dose
Moderna Booster (1/2 dose)
Moderna 3rd Dose Immunocompromised
J&J 1st Dose
J&J Booster
Vaccine Recipient Name
First Name
Middle Name
Last Name
Vaccine Recipient Physical Address
*
Street Address
Apt #
City
State Initials
Zip Code
Date of Birth
*
/
Month
/
Day
Year
Gender at birth
*
Please Select
Male
Female
Race
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Ethnicity
*
Please Select
Hispanic or Latino
Not Hispanic or Latino
Unknown
Vaccine Recipient Phone Number
*
Mother's Maiden Name
Required for proper vaccine documentation
Primary Care Provider Name
Emergency Contact Name
Relationship to Emergency Contact
Please Select
Brother
Sister
Sibling
Mother
Parent
Father
Guardian
Spouse
Grandparent
Child
Foster child
Stepchild
Care Giver
Other
Phone Number of Emergency Contact
Email
*
example@example.com
COVID-19 Vaccine Screen Questions
*
Yes
No
1. Are you feeling sick today?
2. In the last 10 days, have you had a COVID-19 Test because you had symptoms and are still awaiting your test results or been told by a healthcare provider or health department to isolate or quarantine at home due to COVID-19 infection, exposure, or travel?
3. Have you been treated with antibody therapy or convalescent plasma for COVID-19 in the past 90 days (3 months)?
4. 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
5.
Have you received any vaccine in the last 14 days
?
6. Are you pregnant or considering becoming pregnant or breastfeeding?
7. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
8. Do you take any medications that affect your immune system, such as cortisone, prednisone, or other steroids, anticancer drugs, or have you had any radiation treatments?
9. Do you have a bleeding disorder or are you taking a blood thinner?
Which arm would you like to get the injection on
*
Left Arm
Right Arm
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 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 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.
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 Insurance Card
Browse Files
Drag and drop files here
Choose a file
Cancel
of
For uninsured patients, please select at least one of the following that you will bring with you to your appointment.
Social Security Number
State identification number and state of issuance
Driver's license number and state of issuance
Please Upload Supporting Uninsured Document
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):
Date Signed
/
Month
/
Day
Year
Date
Pharmacist Name
First and Last Name
Pharmacist Signature
Immunizer Name
First and Last Name
Immunizer Signature
Lot Number
Expiration Date:
Vaccine Manufacturer
MODERNA
PFIZER
JANSSEN
Pharmacy Name
Submit
Pharmacy NPI
*
Should be Empty: