Section I. Appointment Scheduler

Please do not submit this form unless you are 100% certain you are going to come and get the vaccine at the date and time you select. We are having too many no shows and cancellations after booking appointments. This is preventing the people that really need the vaccine from getting their appointment.

Please pick a day and time for your vaccination*

**Vaccine supply is limited. Please keep your appointment**

Section II. Personal Information

Patient's Name:*

First Name Last Name

Date of Birth:*

Age:*

Must be over 16

Address:*

Street Address Line 2

You must be a resident of GA

State*

Email:*

Phone Number:*

Gender:*

M F

Are you over the age of 16?*

Yes No (Pfizer Vaccine is only approved for age 16 & over. We cannot vaccinate you with this vaccine if you are not over the age of 16)

Race:*

What dose of COVID-19 vaccine will this be?*

First Dose Second Dose (Pfizer Only)

When did you receive your first dose?*

Date

Section III. Questionnaire for Immunization

Please select the correct option below:*

	Yes	No	Don't know or N/A
COVID-19 Screening Questions: 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?
Questionnaire for Immunization: The manufacturer advises against administration of Pfizer COVID-19 Vaccine to individuals with known history of a severe allergic reaction (e.g. anaphylaxis) to any component of the Pfizer COVID-19 Vaccine. It contains: lipids (0.43 mg (4-hydroxybutyl)azanediyl)bis(hexane-6,1-diyl)bis(2-hexyldecanoate), 0.05 mg 2[(polyethylene glycol)-2000]-N,N-ditetradecylacetamide, 0.09 mg 1,2-distearoyl-sn-glycero-3-phosphocholine, and 0.2 mg cholesterol), 0.01 mg potassium chloride, 0.01 mg monobasic potassium phosphate, 0.36 mg sodium chloride, 0.07 mg dibasic sodium phosphate dihydrate, and 6 mg sucrose. 1. Do you have a history of allergic reaction to any of these ingredients listed above?
2. Do you have a history of severe allergic reactions, such as an immediate-onset anaphylaxisto medications, foods, or any vaccines (eggs, gelatin, thimerosal, neomycin, gentamicin, latex, aluminum, preservatives, baker's yeast, etc.)?
3. Have you ever been diagnosed with Guillain-Barre’ syndrome or other neurological disorder related to a vaccine?
4. Have you received any vaccine (flu, pneumococcal, shingles, etc.) within the last 14 days?
5. For women: Are you pregnant or is there a chance you could become pregnant during the next month?
6. Have you received any antibody treatment for COVID-19 in the last 90 days?

Please specify the allergy from Q2:

Section IV. Signatures

I have read, or have had read to me, the written information regarding the vaccine(s) being administered. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s) being administered and have received a copy of a current FACT SHEET FOR RECIPIENTS AND CAREGIVERS EMERGENCY USE AUTHORIZATION (EUA) OF THE PFIZER-BIONTECH COVID-19 VACCINE TO PREVENT CORONAVIRUS DISEASE 2019 (COVID-19) IN INDIVIDUALS 16 YEARS OF AGE AND OLDER. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless West End Pharmacy, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s). I certify that I am at least 18 years old and hereby give my consent to the pharmacists of this West End Pharamcy to administer the vaccine(s). If under 18 years old signature by parent or guardian is required.
I agree to wait near the vaccination location for approximately 15 minutes for observation by the pharmacist.

Signature of Person to Receive Vaccine & EUA/VIS (or Signature of Parent/Guardian if Patient is < 18 yo)*

Use mouse/mouse-pad to Click and Draw Clear

I have received a copy of the notice of Privacy Practices. 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.

Signature of Acknowledgment of Notice of Privacy Practices:*

Use Mouse to Click and Draw Clear

The vaccine will be provided at no cost regardless of you having insurance or not. Please pick one of the following options below.*

I have Medicare I have Medicaid I have commercial insurance I do not have any insurance

Medicare Number*

Medicaid Number*

Rx Bin:*

SHOULD BE 6 NUMBERS

Rx PCN

COULD BE LETTERS OF NUMBERS

Member ID*

Rx Group

Driver's license number or Social Security Number (If you do not have either put No ID in the field below. Your vaccine will still be given to you at no charge)*

Pharmacist Use Only:

Vaccine		Mnf.	LOT	Exp Date	Dose	Site of Injection	Date of EUA/FS	RPH Initials
Covid-19		Pfizer-BioNTech	EW0151	07/30/21	0.3 ml	LD RD	12/2020

Vaccine Card: 1st Dose:

GRITS: 2nd Dose:

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.

Pfizer COVID-19 Vaccine Consent Form