Alden Pharmacy Pediatric Vaccine Form
All sections marked with an asterisk (*) must be completed to schedule a vaccination appointment. Please have your insurance cards and COVID-19 vaccine card (if applicable) available to complete this form.
What vaccine are you scheduling?
*
Pfizer COVID-19 Pediatric vaccine (ages 5-11 years old only)
Has the recipient received a previous dose of the Pfizer COVID-19 vaccine?
*
Yes
No
How many doses of the Pfizer COVID-19 vaccine has the patient received?
*
What were the date(s) of previous Pfizer COVID-19 vaccine administration?
*
Appointment arrival time (please plan to spend about 20 minutes on site for your appointment). Following vaccination you must wait for 15 minutes to be monitored for any signs of an allergic reaction.
*
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Alden Pharmacy COVID-19 Immunization Screening and Consent Form
Recipient Name
*
First Name
Last Name
Recipient Age - must be between 5-11 years old to receive this vaccine
*
Recipient Date of Birth
*
-
Month
-
Day
Year
Date
Recipient Sex Assigned at Birth
*
Male
Female
Intersex
Choose not to respond
Gender
*
Male
Female
Transgender Male
Transgender Female
Non-Binary
Other / Prefer not to respond
What is the recipient's weight (in pounds)?
*
Recipient Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Recipient Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
County of Residence (e.g. Erie)
*
Email Address (required if you want a confirmation email of your appointment)
example@example.com
Name of Primary Care Provider (Your doctor)
*
Type None if you do not have a PCP
Phone Number of Primary Care Provider
*
Please enter a valid phone number.
Format: (000) 000-0000.
Does the recipient have insurance?
*
Yes
No
I certify that I will bring the recipient's social security number so that Alden Pharmacy can bill the Uninsured Program for the cost of administering the COVID-19 vaccine.
*
Yes
What is the name of the recipient's insurance plan for pharmacy coverage? (this may be a different card than used medical coverage)
*
What is the recipient's insurance Rx Bin number? (this is a six digit number that may be on the front or back of your insurance card)
*
What is the recipient's insurance Rx group number?
*
What is the phone number to the insurance plan?
*
Please enter a valid phone number.
Format: (000) 000-0000.
What is the Rx PCN on the insurance card? (may be numbers or letters or both)
*
If you cannot find the PCN on the front or back of the card type None
What is the recipient's insurance ID number?
*
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Is the recipient between the ages of 5 and 11 years old?
*
Yes
No
Is the recipient feeling sick today?
*
Yes
No
In the last 10 days, has the recipient had a COVID-19 test because they were experiencing symptoms and are still awaiting the test results, or been told by a health care provider or health department to isolate or quarantine at home due to COVID-19 infection or exposure?
*
Yes
No
Has the recipient been treated with antibody therapy or convalescent plasma for COVID-19 in the past 90 days?
*
Yes
No
Has the recipient ever had an immediate allergic reaction (e.g. hives, facial swelling, difficulty breathing, anaphylaxis) to any vaccine, injection, or shot, or to any component of the COVID-19 vaccine, or a severe allergic reaction (anaphylaxis) to any medication, food, or substance?
*
Yes
No
If yes, what was the allergy to and what was the reaction?
*
Does the recipient have cancer, leukemia, HIV/AIDS, or any other condition that weakens the immune system?
*
Yes
No
Does the recipient take any medications that weaken the immune system, such as cortisone, prednisone or other steroids, anticancer drugs, or had any recent radiation treatments?
*
Yes
No
Does the recipient have a bleeding disorder, a history of blood clots, or is taking a blood thinner?
*
Yes
No
Does the recipient have a history of myocarditis (inflammation of the heart muscle) or pericarditis (inflammation of the lining of the heart)?
*
Yes
No
Has the recipient received a previous dose of a COVID-19 vaccine authorized by the WHO but not by the FDA (AstraZeneca - VAXZEVRIA, Sinovac - CORONAVAC, Serum Institute of India - COVISHIELD,Sinopharm/BIBP)?
*
Yes
No
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Do you consent to having the recipient's vaccination record shared with the New York State Immunization Registry? (You must consent to receive a vaccination)
*
I consent
I will bring proof of completion of the New York State Vaccine form to the appointment for the recipient. Proof can be a printed confirmation screen or a screenshot of the confirmation screen. The vaccine form is required for all first doses of COVID vaccine in New York State. It can be accessed at this site: https://forms.ny.gov/s3/vaccine
*
I agree
I agree to bring the recipient's insurance card(s) and COVID-19 vaccination card (for second dose or booster dose of the COVID-19 vaccine) to the appointment
*
I agree
I understand that the COVID-19 vaccine is being administered under an FDA Emergency Use Authorization order and that the vaccine is not yet FDA-approved. A copy of the EUA is available on the Alden Pharmacy website. I am consenting the recipient receiving this vaccine.
*
I consent
I understand that once I hit the Submit button I will receive a confirmation screen to confirm my appointment. If I do not receive a confirmation screen, then the appointment time I selected is full and I would need to start over selecting a new appointment time.
*
I understand
By entering your name below, you certify that you are the child's parent or legal guardian and you are authorizing the child to receive the COVID-19 vaccine under the Emergency Use Authorization provided by the FDA. You or another parent or legal guardian must accompany the child to the vaccine appointment and provide proof of identity.
*
First Name
Last Name
Submit
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