COVID-19 Vaccine Appointment and Consent Form
In order to receive the vaccine, you must be in the most appropriate phase of the vaccine rollout. Visit this link (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations.html) for more information at the federal level. States and/or local authorities may have a different approach. Be prepared to show identification to justify your qualification to receive the vaccine.
Vaccine Recipient Name
*
First Name
Middle Name
Last Name
Vaccine Recipient Physical Address
*
Street Address
Street Address Line 2
City
State Initials
Postal / Zip Code
Email (to receive notification of appointment and informational documents)
example@example.com
Date of Birth
*
/
Month
/
Day
Year
1
Gender at birth
*
Please Select
Male
Female
Race
*
Please Select
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Black or African American
White
Other Race
Required by California Department of Public Health
Ethnicity
*
Please Select
Hispanic or Latino
Not Hispanic or Latino
Unknown
Required by California Department of Public Health
Vaccine Recipient Phone Number
*
Format: (000) 000-0000.
Mother's Maiden Name
*
Required for proper vaccine documentation
Primary Care Provider Name
If you would like to have a copy of this record sent to your Primary Care Provider, please provide name here.
Emergency Contact Name
*
Relationship to Emergency Contact
*
Phone Number of Emergency Contact
*
Format: (000) 000-0000.
COVID-19 Previous Dose
*
Rows
Yes
No
Have you ever received a dose of COVID-19 Vaccine?
2
3
COVID-19 Vaccine Manufacturer for the first dose received
Please Select
Moderna
Pfizer
Other
Date of first dose of COVID-19 Vaccine
/
Month
/
Day
Year
4
Previous COVID-19 vaccine dose
Rows
Yes
No
Have you ever had an allergic reaction to a previous dose of COVID-19 Vaccine
?
5
6
COVID-19 Vaccine Screening Questions (If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just means additional information may be necessary before vaccination.)
*
Rows
Yes
No
1. 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?
7
8
2. Have you ever had an allergic reaction to
Polysorbate?
9
10
3. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?
11
12
4. 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.
13
14
5. Have you received any vaccine in the last 14 days?
15
16
6. Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19?
17
18
7. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?
[note: monoclonal antibodies does not include antibiotics that you would be prescribed and filled at a pharmacy]
19
20
8. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
21
22
9. Do you have a bleeding disorder or are you taking a blood thinner?
23
24
10. Are you pregnant or breastfeeding?
25
26
Consent (check each box below after reading and prior to signing the form)
*
Rows
Check each box
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet (the Moderna Fact Sheet is available after clicking submit), a copy of which I was provided with this Consent Form. 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 Form.
27
I understand that at this time, the COVID-19 vaccine requires 2 doses given 21-28 days apart depending on the manufacturer. If this is my second dose, I will bring my vaccine card with me to be completed.
28
I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.
29
I acknowledge that my immunization information from this visit will be sent to the California Immunization Registry unless I choose to opt out.
30
I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Hendricks 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).
31
I have read and reviewed the Notice of Privacy Practices available at www.HendricksPharmacy.flashrx.com.
32
I understand that I will be receiving the vaccination at no cost to me.
33
Insurance (The vaccine is available to anyone no matter if insured or uninsured.)
*
Rows
Yes
No
Do you have health or medical insurance (examples include Medicare, Medi-Cal, or private health policies)?
34
35
The vaccine is available to anyone no matter if insured or uninsured. Since you indicated you have insurance, please read and check this box.
Rows
Check box
If INSURED, check this box attesting to bringing in your prescription and medical insurance cards for your vaccine appointment. By selecting this, you are also authorizing the pharmacy to bill your insurance on your behalf for the immunization – understanding you will not incur any costs.
36
Insurance Card (front & back)
Browse Files
Drag and drop files here
Choose a file
Please upload a copy of the front and back of your Medicare, Medi-Cal, or pharmacy insurance card
Cancel
of
The vaccine is available to anyone no matter if insured or uninsured. Since you indicated you do not have insurance, please read and check this box.
Rows
Check box
If UNINSURED, you must check this box to attest that the 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 benefit plan.
37
For uninsured patients, please select at least one of the following that you will bring with you to your appointment.
Social Security Number
State identification number and state of issuance
Driver's license number and state of issuance
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):
Date Signed
/
Month
/
Day
Year
Date
Select an appointment time
*
Submit Consent Form (required)
Should be Empty: