Covid-19 Specific Vaccination Questions
Covid-19 Vaccine Patient Acknowledgment
Are you requesting a COVID-19 Vaccination:*
Yes No

Is this your first or second vaccination dose question?*
1st Dose 2nd Dose
If this is your second dose, what vaccine was your first?
Moderna Pfizer Don't know
If this is your second dose, when did you receive your first dose:
Month Day Year
Date

Exclusion Questions: Answering yes to either of these questions excludes you from receiving the vaccine.
Do you have a known history of a severe allergic reaction (e.g. anaphylaxis) to this vaccine or any components of the vaccine including lipids, tromethamine, tromethamine hydrochloride, acetic acid, sodium acetate, PEG(Polyethylene Glycol) and sucrose. (Full list is available in the Fact Sheet for Vaccine Recipients and Caregivers or from your health care provider.)*
Yes No

Are you under the age of 18 years?
Yes No

Insurance Information
Have you filled a prescription at Armitage Pharmacy within the past 12 months and we would have your insurance information on file?
Yes No
If we do NOT have your Insurance Information:
Insurance Company Name
Are you the primary cardholder
Yes No
If no to above what is the primary cardholders name?
Primary Cardholders date of birth:
Month Day Year
Date
Cardholder ID:
Rx Group ID:
Rx Card BIN Number:
Card Card PCN Number:
Are you Medicare Eligible
Yes No
If you are Medicare Eligible we need the Medicare ID off your Red,White&Blue ID Card. Such as 1BC2-D03-EF45.
************** It is NOT your Social Security Number *******************
If you are not insured and you do not want to pay for administration of the vaccine yourself, you must provide the information below. If you do not provide this information you may be billed for vaccine administration.
I do not have any insurance, including but not limited to Medicare, Medicaid, or any other private or government-funded health benefit plan. 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 (a) a valid Social Security number, or (b) state identification number and state of issuance, or (c) a driver’s license number and the state of issuance:
Then please enter your "Primary Care" provider name and phone number.
Enter your Primary Care provide and phone number.
Acknowledgements:
I made the choice to get the COVID-19 vaccine on my own and freely. I know I have the option to refuse the vaccine. I ask that the vaccine be given to me, or to the person named above for whom I can make this request. I was given the (Fact Sheet for Vaccine Recipients and Caregivers) for this vaccine. The fact sheet has information about side effects and adverse reactions. I read or had read to me the information provided about the COVID-19 vaccine.
   I know the Food and Drug Administration (FDA) has authorized the emergency use of this vaccine. I know it is not a fully licensed FDA vaccine. I had the chance to ask questions that were answered to my satisfaction. I now know about the vaccine, alternatives, benefits, and risks, to the extent they are known and unknown at this time.
   I know that I must stay in the vaccine area or an area told to me by my health care provider after I receive my immunization so I am near my health care provider if I have any adverse reactions. If I have a history of severe allergic reaction, (e.g. anaphylaxis), I must stay for 30 minutes. If I do not have a history of severe allergic reaction, I must stay for 15 minutes
   I know that if I have a severe allergic reaction, including difficulty breathing, swelling of my face and/or throat, a fast heartbeat, a bad rash all over my body or dizziness and weakness I should call 9-1-1 or go to the nearest hospital. I know I can call my health care provider if I have any side effects that bother me or do not go away.
I was asked to join the V-SAFE program. The program does health checks on the people who get the COVID-19 vaccine. I know I should report vaccine side effects to FDA/CDC Vaccine Adverse Event Reporting System (VAERS) at 1-800-822-7967 or https://vaers.hhs.gov/reportevent.html.
   I know I must get two doses of the COVID-19 vaccine and receive the same vaccine each time. I know that with all vaccines there is no promise I will become immune (not get the virus) or that I will not have side effects. I know I may choose to not get the second dose of the vaccine. But if I do not get the second dose, the chance that I will become immune may go down.
Authorization to Request Payment: I authorize the organization providing my vaccine to release information and request payment. I certify that the information given by me in applying for payment under Medicare or Medicaid or the HRSA COVID-19 Program for Uninsured Patients, is correct. I authorize release of all records to act on this request. I request that payment of authorized benefits be made on my behalf.
Disclosure of Records: I understand the organization providing my vaccine may be required to or may voluntarily disclose my vaccine-related health information to my primary care physician, my insurance plan, health systems and hospitals, and state or federal registries or other public health authorities, for purposes of treatment, payment or health care operations. I also understand the organization providing my vaccine will use and disclose my health information as described in its Notice of Privacy Practices which I may receive upon request or find on its website . If I am an employee of [insert name of health care provider] I understand that it will keep records of this vaccination for me in [insert name of electronic health record] and may keep my vaccination records in [insert name of health care provider]’s employee occupational health records, to the extent required or permitted by law.
Patient Signature
Clear
Date
Month Day Year
Date
This finishes your consent form for Covid-19 vaccine, press submit and the pharmacy will receive you form

Appointment

You may wish to start over or you may exit at this time.

We are sorry but you are unable to receive the vaccine at this time, please speak with one of the Pharmacists concerning this.
Thank you for your understanding.
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Covid-19 Specific Vaccination Questions

This finishes your consent form for Covid-19 vaccine, press submit and the pharmacy will receive you form

Influenza and other Vaccines Consent Form