24-25 Asti's Rx - Multi-Vaccine Scheduler/Assessment (Adult & Pediatric)

'24-'25 Asti's South Hills Pharmacy Multi-Vaccine Scheduler and Pre-Vaccination Assessment (Adult and Pediatric)

PLEASE READ THE FOLLOWING QUESTIONS CLOSELY
*Please read all questions carefully*
Clinic Name (For offsite clinic events only)
SKIP this question if scheduling an in-pharmacy appt.
Vaccine Recipient Name*

First NameLast Name
Vaccine Recipient Address*

Street Address

Street Address Line 2

CityState Initials

Zip Code
Social Security Number*
Gender at Birth*
Date of Birth*

MonthDayYear
Note: Certain vaccines have age restrictions
Age*
Vaccine Recipient Phone Number*
Email*

Confirmation Emailexample@example.com
Primary Care Provider Name*
Emergency Contact Name*
Emergency Contact Relationship to Vaccine Recipient*
ie. Spouse, Mother, Father, Daughter, etc.
Emergency Contact Phone Number*
Please enter a valid phone number.
What type of insurance coverage do you have?
Insurance Selection Helper

Based on your answer to the prior question, please attest to only one of the statements below:*

	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.

For Medicare: Please upload a photo of your Medicare Card, the "Red White and Blue" Card. We do not need other insurance information.
For Commercial Insurance: Please upload a photo of your insurance card(s) here. You may have Medical Coverage that is different from your Pharmacy Coverage - please include a copy of BOTH cards. You can upload multiple pictures at a time! Front and Back of Cards is Necessary.
For Medicaid: Please upload a photo of your insurance card(s) here. You may have an Insurance Company Card, as well as an Access card. Please include a copy of BOTH cards. You can upload multiple pictures at a time! Front and Back of Cards is Necessary.
For Uninsured: Please upload a photo of your Driver's License or your State Identification Card. You can also upload a photo of your Social Security Card. You can upload multiple pictures at a time!
Cancelof
Having trouble uploading your card?
Insurance Plan Name*
ie. Highmark, UPMC, etc.
Insurance Member ID*
Primary Insurance Card
Insurance Group Number*
Primary Insurance Card
Which vaccine(s) are you scheduling? (select all that apply)*

Influenza (Flu Shot Age 3+)HD Influenza (Flu Shot Age 65+)Shingles (Age 50+)PneumoniaTdap (Tetanus, Diptheria, & Pertussis)Hepatitis AHepatitis BTwinrix (combined Hep A & Hep B)RSV (Respiratory Syncytial Virus Vaccine) Age 60+
Attention:

A scheduled appointment is NOT required for non-COVID Vaccine appointments. We offer all vaccines (except COVID) during normal buisiness hours.

We kindly ask that you contact the pharmacy to let them know when to expect you (412-561-2347). This will help ensure that we reserve inventory for your visit.

Thank you!
STOP

We apologize, but we are not currently stocking the Pediatric COVID Vaccine for children under 12 years of age. If you are in need of this vaccine for a child, we can help direct you to another vaccine provider. Please contact the pharmacy at 412-561-2347 for assistance. Thank you!
Please Attest that you are the Legal Parent or Guardian for the Vaccine Recipient

Yes, I attest to be the legal parent or guardian for the child vaccine recipientI cannot confirm that I am the legal parent or guardian for the child vaccine recipient
Name of Parent or Guardian

First NameLast Name
Relationship to Vaccine Recipient
Which COVID Vaccine dose are you scheduling?
Which manufacturer are you requesting for your booster dose?
Booster Dosing Information:

Currently, Booster Doses are approved using the updated, bivalent formulations from Pfizer and Moderna. The bivalent formulation covers the original virus strain, as well as the omicron variant. This new formulation will be used for all booster doses as of 9.1.22.

Visit the CDC website for more information.
*ATTESTATION* Additional Doses are limited to certain populations. Please attest that you are aware of eligibility limitations (CDC.gov), and can confirm you are indeed eligible.

Yes, I am aware of my eligibility and attest that I qualify for an Additional DoseNo, I do not believe I am eligible
*ATTESTATION* Booster Doses are now recommended in children (>12 yo, pfizer only) and adult populations 5 months after completing an mRNA vaccine series or 2 months after receiving the J&J vaccine . A 2nd Booster Dose has been approved in patients 50+ years old at least 4 months after receipt of a 1st Booster Dose. Please attest that you are aware of eligibility limitations (CDC.gov), and can confirm you are indeed eligible.

Yes, I am aware of my eligibility and attest that I qualify for a Booster DoseNo, I do not believe I am eligible
COVID Vaccine manufacturer preference? (SUBJECT TO AVAILABILITY)
*IMPORTANT* Please note vaccine storage limitations may not allow us to accommodate vaccine preference! If you require a specific vaccine for your first dose, it is recommended that you contact the pharmacy before proceeding to confirm inventory. Thank you!
Who provided you with your 1st Dose?
Who manufactured your 1st dose?
On what date did you receive your 1st dose?

MonthDayYear
Date of 1st Dose
Did you receive your 2nd dose as scheduled?
Clinic Location and Address
Pharmacy Use Only
Appointment Scheduler*
VERY IMPORTANT

You will need to schedule a 2nd Dose Appointment by submitting a new request of this same form.

Based on the vaccine you receive for your first dose, you must schedule a 2nd Dose Appointment at the following, preferred interval:

* Pfizer Vaccines: 3 weeks (or 21 days)

* Moderna Vaccine: 4 weeks (or 28 days)

Please book the 2nd Dose Appointment as soon as possible in order to reserve your spot. If no appointments are available on the recommended date, please contact the pharmacy at admin@astisrx.com.

THANK YOU

Vaccine Screening Questions*

	Yes	No
1. Are you feeling sick today?
2. Have you received a vaccine within the last 4 weeks?
3. Are you allergic to any medication, latex, vaccine, or vaccine component?
4. Have you ever had a severe allergic reaction to anything, including medications, vaccines, food, environmental, etc.?
5. Have you ever tested positive for COVID-19 or has a health care provider ever told you that you had COVID-19?
6. 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]
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 such as: cortisone, prednisone, steroids, Humira, Enbrel, etc.?
8. Do you have a bleeding disorder or are you taking a blood thinner?
9. Are you pregnant or breastfeeding?
10. Do you have a history of Guillain-Barre Syndrome?

Consent (check each box below after reading and prior to submitting 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 specific vaccine Fact Sheet is available after final submission), 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 my COVID-19 vaccine may require 2 doses given 21-28 days apart depending on the manufacturer (unless you are receiving the J&J vaccine). 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.

Signature of Person (or guardian) to Receive Vaccine & EUA/VIS*

Clear
Date Signed*

MonthDayYear
Today's Date
Pharmacy Use ONLY
Name & Title of Immunizing RPh or Intern
Signature of Immunizing RPh or Intern

Clear
Vaccine Administered
Lot Number
Expiration Date
Administration Site

Additional Vaccines Administered

	Vaccine Administered	Lot Number	Expiration Date	Administration Site
Second Vaccine
Third Vaccine
Fourth Vaccine

Date Administered and VIS Provided

MonthDayYear
Asti's South Hills Pharmacy is committed to helping our community overcome this pandemic. Our mission is 'To create lifelong relationships by bettering the lives of all we touch', and we view the opportunity provide you all with access to this critical vaccine as a privilege. Thank you for trusting in us as your pharmacy provider!
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'24-'25 Asti's South Hills Pharmacy Multi-Vaccine Scheduler and Pre-Vaccination Assessment (Adult and Pediatric)

*Please read all questions carefully*

Pharmacy Use ONLY

Please read all questions carefully