RETAIL COVID-19 Vaccine Consent Form

Catonsville Pharmacy

6350 Frederick Rd; Baltimore, MD 21228

Phone 410.744.5959 ~ Fax 410.744.4810

www.YOURCommunityPharmacy.com

Please READ ALL of the information below.

1) We are providing COVID-19 vaccines on a walk-in ONLY basis (no appointments) on a rotating schedule.

Pfizer Bivalent Boosters (12yo+) - Mon-Fri 9:30 am to 5 pm

*Pediatric* Pfizer Bivalent Boosters (5-11 yo) - Thurs and Fri 9:30 am to 5 pm

Moderna Bivalent Boosters (6yo+) - Wed and Fri 9:30 am to 5 pm

2) Please submit this form. If able, please print prior to submitting and bring your copy. If not able to print, please alert the cashier that you submitted online.

3) BEFORE ARRIVING:

Please READ the following EUA (Emergency Use Authorization) for Recipients/Caregivers for the vaccine that you wish to receive upon arrival:

Moderna EUA for Recipients

Pfizer Adult (12yo+) EUA for Recipients

Pfizer Peds (5-11yo) EUA for Recipients

3) BRING WITH YOU:

a) Copy of consent form

b) Copy (front and back) of your prescription insurance card and/or Medicare (Red, White, Blue, if 65yo+).

c) State Issued Photo ID (if applicable)

d) 2nd doses or boosters - Vaccination record card or printout from https://md.myir.net/, if able

4) WHEN YOU ARRIVE

a) We are at 6350 Frederick Rd, Catonsville, next to the 7-11 in the Paradise community.

b) Turn right when you enter the pharmacy and proceed to the line at aisle 5 to register with the cashier prior to receiving your vaccination.

COVID-19 Vaccine Requested

Name

First NameLast Name

Patient Email Address

Date of Birth

Date

Age

Gender:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Primary Care Physician (if applicable)

Primary Care Phone (if known)

Please enter a valid phone number.Format: (000) 000-0000.

Primary Care Fax (if known)

Please enter a valid phone number.Format: (000) 000-0000.

Race

Ethnicity

Have you Screening Questions - if you answer "yes" please include details in the comment section

Rows	YES	NO	Unsure
Do you feel sick today?
Have you received a dose of COVID-19 vaccine before today? If Yes, please bring your vaccination card with you!
Have you ever had a serious allergic reaction to something? (ie. that you needed an "Epi-Pen" or had to go to the hospital) *You will be required to stay for 30 min after your vaccine
Have you received another (non-COVID) vaccine in the last 14 days? If Yes, please put name in comments
Have you ever had a severe allergic reaction after receiving another vaccine or injectable medication? If yes, please enter name in comments and you will be required to stay for 30 min after your vaccine)
Have you had a positive test for COVID-19 in the last 90 days?
Have you received monoclonal antibodies or convalescent plasma as treatment for COVID-19 in the last 90 days?
Do you have a weakened immune system caused by a medical condition (HIV, cancer, etc) or immunosuppressive drug therapy?
Are you pregnant (or think you may become pregnant in the next month) or breastfeeding?

Comments to any Yes Answers

*Persons who have had a severe reaction to a vaccine or currently have an acute febrile illness should not receive a vaccine. I consent to the staff to administer the vaccination(s) mentioned below. I understand that this vaccine has been authorized by the FDA under an Emergency Use Authorization and I have reviewed the fact sheet available above concerning the specific manufacturer of the vaccine I am receiving. I understand the benefits and risks of receiving this vaccine and choose to assume this risk. I fully release and discharge the pharmacist and the pharmacy, its affiliations, and their officers and employees from any illness, injury, loss, or damage that may result therefrom. I acknowledge that I have received a copy of the pharmacy's privacy policies according to HIPAA. I assign payment of authorized insurance benefits due to me to be paid to the pharmacy. I consent to the release of medical information when necessary for billing, reimbursement, and medical protocol. I also allow for the pharmacy to report any vaccinations received to the appropriate state vaccine registry. I am aware that an immunization certified student pharmacist might be administering this vaccine. I agree to wait near the vaccination area for a minimum of 15 minutes or as otherwise instructed by the pharmacist so that I may receive treatment if I begin to feel unwell.

Signature

Printed Name

Date Signed

Date

Medicare Part B ID Number

Medicare Pt B Effective Date

Date

Private Prescription Insurance ID Number

Prescription Insurance Help Desk Number (on Card)

Please enter a valid phone number.Format: (000) 000-0000.

Bin # (on Rx card)

RX Group (on Rx Card)

Rx PCN Number (on Rx Card)