2022-08-24 - Flu and COVID-19 Vaccine Appointment Request and Consent Form Logo
  • Vaccine Appointment Request and Consent Form

  • Pediatric Associates is excited to offer online appointment requests for Flu and COVID-19 vaccinations!

    Our providers recommend all eligible children receive both the COVID-19 vaccine and the flu vaccine this season, even during the same visit.

    If your child is not a current patient we will not be able to schedule an appointment through this form.  Please CLICK HERE to request to become a patient!

    We are able to administer the vaccine at all 3 offices however due to limited availability and storage requirements our satellite offices have limited availibility.

    Please complete the form and we will contact you to confirm your request no later than 48 hours prior to your appointment.

    We are offering a WEEKEND FLU CLINIC on limited dates at our MAIN office on Waters Avenue!  Please select "MAIN OFFICE" then "WEEKEND CLINIC" to sign up!

  • Main Office

    4600 Waters Ave., Suite 100, Savannah, GA 31404
  • Pooler Office

    110 Medical Park Drive, Pooler, GA 31322
  • Whitemarsh Island Office

    1001 Memorial Dr, Savannah, GA 31410
  • Patient Information

  • Flu Vaccine Consent

  •  
  • COVID-19 Vaccine Consent

  • If you are unsure which vaccine dose your child requires please call our office before completing this form or review the CDC's recommendations at the links below:

    General COVID-19 Vaccine information:

    https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/children-teens.html

    Booster Dose information:

    https://www.cdc.gov/coronavirus/2019-ncov/vaccines/booster-shot.html#when-you-can-get-booster

  • I declare that the recipient:

    • Has NOT had an allergic reaction* to the any of the following: 

      An allergic reaction would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or caused the recipient togo to the hospital. It would also include an allergic reaction that caused hives, swelling, or respiratory distress, including wheezing

      • Polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures
      • Polysorbate, which is found in some vaccines, film coated tablets, and intravenous steroids
      • A previous dose of an mRNA COVID-19 vaccine
    • I understand the recipient could be at increased risk of having a negative reaction or problem from the vaccine if any of the following are true: 
      • Is currently sick with a fever, active respiratory infection or other moderate/severe illness and I will notify the office immediately if these symptoms occur at any point prior to the appointment
      • Is a female between ages 18 and 49 years old
      • Is a male between ages 12 and 29 years old
      • Has a history of myocarditis or pericarditis
      • Has had a severe allergic reaction to something other than a vaccine or injectable therapy such as food, pet, venom, environmental or oral medication allergies
      • Had COVID-19 and was treated with monoclonal antibodies or convalescent serum
      • Diagnosed with Multisystem Inflammatory Syndrome (MIS-C or MIS-A) after a COVID-19 infection
      • Has a bleeding disorder
      • Takes a blood thinner
      • Has a weakened immune system (i.e., HIV infection, cancer) or take
        immunosuppressive drugs or therapies
      • Has a history of heparin-induced thrombocytopenia (HIT)
      • Is currently pregnant or breastfeeding
      • Has received dermal fillers
      • Has a history of Guillain-Barré Syndrome (GBS)
    • I understand that the common risks associated with the COVID-19 vaccine include but are not limited to pain, redness or swelling at the site of injection, tiredness, headache, muscle pain, chills, joint pain, fever, nausea, feeling unwell or swollen lymph nodes (lymphadenopathy).
    • I understand that the vaccine may cause a severe allergic reaction which can include anaphylaxis (difficulty breathing, swelling of the face and throat, a fast heartbeat, a rash all over the body, dizziness and/or weakness ). I understand that these may not be all the side effects of the COVID-19 vaccine as the vaccine is still being studied in clinical trials.  I also understand that it is not possible to predict all possible side effects or complications which could be associated with the vaccine. I understand that the long-term side effects or complications of this vaccine are not known at this time.
    • I have had the opportunity to speak with the recipients primary care provider prior to completing this form and am making an informed decision for the recipient to receive the vaccine
    • I understand that the COVID-19 vaccine is a two-part vaccine series. By signing this consent, I am agreeing that I or my child will receive the first and second part of the vaccine series as scheduled
    • I understand and agree that Pediatric Associates of Savannah, PC is required to submit COVID-19 vaccine administration data to the Georgia Registry of Immunization Transactions & Service (GRITS) and report moderate and severe adverse events following vaccination to the Vaccine Adverse Event Reporting System (VAERS).
    • I understand that the vaccination is being given by Pediatric Associates of Savannah, PC. The owner and/or operator of this site, their affiliates, officers, directors, employees and agents expressly disclaim any responsibility for the vaccination. My consent is given in light of this knowledge, and in consideration of Pediatric Associates of Savannah, PC giving the COVID-19 vaccine. I, for myself and my heirs, administrators, trustees, executors, assigns and successors in interest do hereby agree to release and hold harmless Pediatric Associates of Savannah, PC, its subsidiaries, divisions, affiliates, successors, assigns, officers, trustees, employees, volunteers and agents from and against any and all demands, damages, losses, costs, expenses, obligations, liabilities, claims, actions and cause of action (whether any of which is groundless or otherwise) of any nature whatsoever (including, without limitation, reasonable attorney’s fees and court costs) by reason of or resulting, in any way, from any and all acts, accidents, events, occurrences, omissions and the like related to, or arising out of, directly or indirectly, my receipt of this COVID-19 vaccine. Pediatric Associates of Savannah, PC makes no warranties, express or implied, including but not limited to, implied warranties of merchantability or fitness for a particular purpose regarding the vaccine or its effectiveness.
    • I agree to WAIT in the designated clinic location for 15 minutes after receiving the vaccine. If I or my child have previously had a severe allergic reaction to a vaccine or injectable medication, I agree to WAIT in the clinic location for 30 minutes after receiving the vaccine. I agree to seek immediate help for any concerns of a reaction.
  • Consent for vaccination

  • Clear

  • By clicking submit I agree to all of the above and I hereby give my consent to the staff of Pediatric Associates of Savannah, PC to give the recipient all vaccines requested.  I understand the date and time of the appointment is not finalized and will wait for further confirmation from Pediatric Associates of Savannah, PC.

  •  
  • Should be Empty: