• Vaccination Screening & Consent Form

  • Please select which vaccines you would like to receive:*

  • Patient Information

  • Current Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender*
  • Format: (000) 000-0000.
  • Did you receive a previous COVID-19 vaccination at this location?

  • Screening

  • Are you feeling sick today?
  • Have you ever tested positive for COVID-19 or has a doctor ever told you that you have COVID-19?
  • Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?
  • Did you have an allergic reaction to a previous dose of COVID-19 vaccine or to polyethylene glycol (PEG) or polysorbate? (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)
  • Have you ever had an allergic reaction to another vaccine or an injectable medication?
  • Have you ever had a severe allergic reaction to anything else including food, pet, environmental, or oral medications that required hospitalization or use of epinephrine?
  • Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
  • Do you have a bleeding disorder or are you taking a blood thinner?
  • For women, are you pregnant or breastfeeding?
  • Do you have a history of myocarditis or pericarditis?
  • Have you been diagnosed with Multisystem Inflammatory Syndrome (MIS-C or MIS-A) after a COVID-19 infection?
  • Have you had Guillain-Barré Syndrome (GIS)?
  • Do you have a history of fainting, particularly with vaccines?

  • Insurance Information

  • Insurance Card

    Please use your device camera or choose an image to upload. If you are unable to provide images, please present your card when you arrive at the pharmacy.
  • Insurance Card (front)
  • Insurance Card (back)

  • In order to have your vaccine administration fee paid for by the United States Health Resources & Services Administration's COVID-19 Program for Uninsured Patients, please provide either (a) a valid Social Security number, (b) state identification number and state of issuance, OR (c) a driver's license number and the state of issuance.

  • Consent

  • I have read or have had explained to me the information provided in the Emergency Use Authorization (EUA) Factsheet or Vaccine Information Statement about COVID-19 vaccine.  I have had a chance to ask questions that were answered to my satisfaction.  I understand the benefits and risks of COVID-19 vaccine and ask that the vaccine be administered to me or to the person named above for whom I am authorized to make this request.

  • 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 Vaccine Information Sheet. I on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Dotzler Pharmacies Inc., its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with,or any way related to the administration of the vaccine(s). I certify that I am at least 18 years old and hereby give my consent to the pharmacists of Dotzler Pharmacies Inc. 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.

  • *** Self attestation for COVID-19 vaccine eligibility is required for patients in your age category.  You will be redirected following submission of this form. ***

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: