COVID Vaccine Consent Form - Lascassas Drugs

COVID Vaccine Consent Form - Watertown Drugs

Omicron Booster is here!
Section I. Personal Information
Patient's Name:*

FirstMlLast
Date of Birth: (mm/dd/yyy)*

MonthDayYear
Age
Vaccine is now available for everyone ages 18 and older (we carry Moderna brand so you have to be 18 to receive it)
Address:*

Street address

Street Address Line 2

City State

Zip code
Email:*
Phone Number:*
Gender:*

MaleFemale
Ethnicity:*

Hispanic or LatinoNon Hispanic or LatinoUnknownPrefer not to answerOther
Race:*

African AmericanAmerican IndianAsianCaucasianNative Hawaiian/Other Pacific IslanderPrefer not to answerOther
Please take or upload pictures of front of red white and blue medicare card or other insurance cards for billing purposes. Even patients with Medicare Advantage plans must bring a copy of their Medicare part B card or an administration fee may be charged.

Upload your Photo
If you cannot get card uploaded please bring with you. Cancelof
Billing Authorization*

I authorize the pharmacy to bill my insurance on my behalf for the immunization
Are you one of the following? (if none of these apply to you then you are not within the TN vaccination guidelines at this time) *

First ResponderHealthcare Worker18 or over with one of the following conditions (cancer, chronic kidney disease, COPD, heart conditions, coronary artery disease or cardiomyopathy, obesity, pregnant, sickle cell disease, type 2 diabetes mellitus) 1cAge 65+ (1b)Age 55+ (2a, 2b)Teacher K-12NONE of the above
Section II. Questionnaire for Immunization
What dose of COVID-19 vaccine will this be?*

First DoseSecond DoseThird Dose (Immunocompromised dose)Booster2nd BoosterOmicron Booster
Third dose (Immunocompromised dose): The CDC is recommending that moderately to severely immunocompromised people recieve an additional dose. This includes people who have:

Active cancer
Organ transplant
Stem Cell transplant
HIV infection
High-dose corticosteroids or other drugs that may suppress your immune response
Signature attesting to qualification for third dose*

Clear
When did you receive your first dose?*

MMDDYYYY
When did you receive your second dose?*

MonthDayYear

Please answer the following*

	Y/N	Please elaborate "yes" answers here if needed
Have you ever had an allergic reaction to: A component of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures, Polysorbate, or a previous COVID vaccine?
Have you ever had an allergic reaction to another vaccine (other than COVID-19) or any injectable medication?
Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a component of COVID-19 vaccine, polysorbate, or any vaccine or injectable medication? This would include food, pet, environmental, or oral medication allergies.
Have you received COVID-19 monoclonal antibodies or convalescent plasma in the last 90 days?
Have you ever had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?
Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
Do you have a bleeding disorder or are you taking a blood thinner?
Are you pregnant or are you planning on becoming pregnant during the next month?
Have you received any other vaccines in the past 2 weeks?

Todays date

MonthDayYear
Please specify the allergy from Q4:
**Know that if you schedule an appointment and do not qualify for the current phase your submission will be deleted. Additionally, we have strict guidlines that we must follow and have to plan accordingly for each day. So, please keep your appointment or call us if you need to cancel it. And if you miss an appointment, no doses will be held to guarantee your dose.**
*Please pick a day and time for your vaccination*
Section IV. Signatures

I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA), https://www.modernatx.com/covid19vaccine-eua/eua-fact-sheet-recipients.pdf a copy of which I was provided with this Consent and Release. 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 and Release.
Section IV. Signatures

I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA), https://eua.modernatx.com/covid19vaccine-eua/bivalent-dose-HCP.pdf a copy of which I was provided with this Consent and Release. 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 and Release.
Signature of Person to Receive Vaccine & EUA/VIS (or Signature of Parent/Guardian if Patient is < 18 yo)*

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:*

Clear
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.
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COVID Vaccine Consent Form - Watertown Drugs