COVID Vaccine Consent Form

COVID Vaccine UNIVERSAL FORM
Please read this entirely and fill out the required details below. This form is HIPAA Compliant.
CLINIC LOCATION
The Former Best Buy Building
Hudson Valley Mall, 1300 Ulster Ave, Kingston, NY 12401

CLINIC DATE AND TIME
Thursday 3-18-21 from 3pm-7pm
IF YOU ARE COMPLETING THIS ON BEHALF OF SOMEONE
Please ask them to get a PEN and PAPER because they have to write down a unique ID number, their appointment information, and instructions for clinic day
This is step 1 of 3. Here are the steps that need to be completed for each patient:
1. Registration with our system and appointment scheduling (this form)
2. Registration with NYS Department of Health (will be linked after submission of this form)
3. Important instructions to make the very busy day easy, fun, and smooth (will be included after submission)
This entire process should take 5-10 minutes. Please do not share the link to this form with anyone; it is only for the people you have been assigned.
GENERIC CLINIC TEXT
This clinic is currently reserved for patients 60 and over OR teachers for FIRST DOSES of Moderna COVID Vaccines.
NYS DOH's Definition of Teachers
(as per their guidance found here)
P-12 school (public or non-public) or school district faculty or staff (includes all teachers, substitute teachers, student teachers, school administrators, paraprofessional staff, and support staff including bus drivers)
Contractor working in a P-12 school or school district (including contracted bus drivers)
Licensed, registered, approved or legally exempt group childcare
In-person college faculty and essential in-person staff
IMPORTANT NOTE ABOUT THE SIGNUP PROCESS:
Due to the overwhelming volume, we are unable to assist with technical difficulties. If it doesn't work out today, you WILL get a shot soon. Deep breath.
We are not accepting any phone calls regarding COVID support. If you have questions, please email vaccine@drnealsmoller.com. Please do not call the store.
STANDBY LIST TEXT
We are required to maintain a standby list to ensure no COVID vaccine doses are wasted.
This does not guarantee a spot in an upcoming clinic.
READ THIS SENTENCE CAREFULLY: If you did not receive this link DIRECTLY from Neal, you will be removed from this list permanently and the person who shared the link to you will be removed as well.
You are being sent this because you are eligible to receive the vaccine as per NYS now and I believe you can get to our clinic with very little notice.
Filling out this form will ensure we have all necessary information.
After you receive confirmation, follow the instructions to be prepared if we contact you on clinic day to come get a dose.
If you have remaining questions, please email our Vaccine Support: vaccine@drnealsmoller.com.
Doses Available:
600
Which Community Group is this patient a part of?*
Please enter your Date of Birth*
MonthDayYear
Date
Are you a teacher?*
YesNo
What is the grade/course and at what school do you teach?*
What dose of COVID vaccine will this be?
FirstSecond
Have you received COVID-19 monoclonal antibodies or convalescent plasma in the last 90 days?
YesNo
Have you received any other vaccine in the past 14 days?
YesNo
You are not eligible for this clinic.
This clinic is for the first dose of patients 60 or older or teachers (as defined by NYS DOH) who have not been treated with COVID antibodies in the last 90 days or have not had any other vaccine within 14 days.
Section I. Personal Information
When entering your name, do NOT write middle initials. PLEASE write any suffix (Jr, III).
Patient LEGAL First Name ONLY*
Patient LEGAL Last Name ONLY*
Biological Sex:*
MaleFemale
Phone Number:*
Email*

Confirmation Emailexample@example.com
Address
Which of the following best describes your ethnic group?*
Hispanic or LatinoNot Hispanic or LatinoOther / Unknown / Prefer not to answer
Which of the following best describes your race?*
Native AmericanAlaska NativeAsianBlack or African AmericanNative HawaiianOther Pacific IslanderWhiteOther / Unknown / Prefer not to answer
Which location (and date) is best for you?*
Wednesday 3/3 at the Saugerties Jr High School GymThursday 3/4 at the Kate Walton Field House in Kingston
Primary Care Doctor:*
Doctor City/State:*
Do you have any allergies to medicines?
No known drug allergiesYes (enter them below)
Please enter any and all drug or food allergies:
Section II. Questionnaire for Immunization

Section III. Signatures
In an attempt to reduce paper waste, all legally required documents must be downloaded here. Very limited copies will be available on clinic day.
If you are completing this on behalf of someone else, please download these documents and email them to the patient.
If they do not have email, limited copies will be available for them on clinic day.
All copies are available at drneal.co/vax.
REQUIRED DOCUMENTS:
Click this to download the Emergency Use Authorization for the Moderna Vaccine.
Click this to download the Notice of Privacy Practices
Click this to download the CDC vSafe app flyer
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA), a copy of which I was provided with this registration.
I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.
I certify that I have received, read, and understand the Emergency Use Authorization.
I certifty that I have received the Notice of Privacy Practices.
I certify that I have received the CDC vSafe informational flyer.
Please type your full name in the box below. You agree your typed full name represents your electronic signature is the legal equivalent of your manual signature on this form.
Type Your Full Name as Electronic Signature*
Insurance Billing for the Administration of the Vaccine*
I authorize the pharmacy to bill my insurance on my behalf for the immunization. I understand this vaccine will have no cost to me.
If uninsured, you must check the box below to attest that 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 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 select to provide one of the following:*
Social Security NumberState identification number and state of issuanceDriver's license number and state of issuance
Social Security Number*
State identification number and state of issuance*
Driver's license number and state of issuance*
Section IV. Appointment Confirmation
**Vaccine supply is limited. Please keep your appointment.**
Additionally, due to vaccine requirements; we may call you to see if you can come earlier, later or to a nearby location.
If you miss an appointment, no doses will be held to guarantee your dose in the future.
Choose Your Appointment Time: We are accepting 15 people every 5 minutes. (PLEASE FILL EARLIEST SLOTS BEFORE MOVING LATER!)*
Choose Your Appointment Time: We are accepting 15 people every 5 minutes. (PLEASE FILL EARLIEST SLOTS BEFORE MOVING LATER!)*
By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.
Should be Empty:

	Yes	No	Don't know or N/A
In the past two weeks, have you tested positive for COVID-19 or are you currently being monitored for COVID-19?
In the past two weeks, have you had a known exposure with anyone who tested positive for COVID-19?
Have you had a new onset of fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, nausea, vomiting, or diarrhea?
Have you ever had a serious or life-threatening allergic reaction (hives, difficulty breathing) to any vaccine or shot?
Do you carry an EpiPen?

COVID Vaccine UNIVERSAL FORM

Section I. Personal Information

Section II. Questionnaire for Immunization

Section III. Signatures

Section IV. Appointment Confirmation