COVID 19 Patient and Admin Form

Recipient Name: *

First Name Last Name

Recipient Date of Birth: *

Date

Recipient Email: *

example@example.com

Recipient Home Phone #: *

Recipient Mobile Phone #:

Recipient Address: *

Street Address

County

City State

Zip Code

Recipient Race: *

American Indian or Alaska Native Asian Black or African American White Other Race

Recipient Ethnicity: *

Hispanic or Latino Not Hispanic or Latino

Recipient Gender: *

Male Female Unknown

Recipient Preferred Method of Contact: *

Email Text/SMS Message Both None

Is the recipient an Essential Frontline Worker (e.g., Police, Food Processing, Teacher?) *

Yes No

Employer Name: *

Does the recipient reside or work in a long term care facility? *

Yes No

Facility Name: *

Is the recipient part of a state or federal recognized tribal nation? *

Yes No

Community Name: *

Have the recipient tested positive for Covid-19 within the last 30 days? *

Yes No

How many conditions known to increase risk of severe illness from COVID-19 does the recipient have? (Conditions shown below) *

None One Two of More

Asthma (moderate-to-severe)
Cancer
Cerebrovascular disease
Chronic kidney disease
COPD (chronic obstructive pulmonary disease)
Cystic fibrosis
Heart conditions (e.g. heart failure, coronary artery disease, cardiomyopathies)
Hypertension or high blood pressure
Immunocompromised
Liver disease

Neurologic conditions (e.g. dementia)
Overweight (BMI > kg/m2 or higher, but < 40 kg/m2
Severe Obesity (BMI > 40kg/m2)
Pregnancy
Pulmonary fibrosis
Sickle cell disease
Smoking
Thalassemia
Type 1/Type 2 diabetes mellitus

For additional information on conditions: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html

DISCLOSURE STATEMENT: Life-threatening allergic reactions to vaccines are very rare. Signs of a serious allergic reaction include: shortness of breath, hoarseness of wheezing, hives, paleness, weakness, elevated heart rate, or severe dizziness. These symptoms may occur within a few minutes or up to 48 hours after the vaccination. If the recipient is experiencing any of these symptoms, the recipient has been instructed to contact a healthcare provider immediately.

*VERBAL CONSENT: The recipient or legal guardian has been provided the benefits and potential adverse reactions, and provides consent to receive the vaccine.

INSURANCE INFORMATION/AUTHORIZATION TO BILL (copy of front and back of insurance card preferred for verification)

Insurance Name *

Member ID *

Group Number *

Phone Number *

Medical Claims Address *

Subscriber Name *

Subscriber Date of Birth *

Date

Subscriber Social Security Number (if Tricare) *

Check here if mailing address for subscriber is the same as the vaccine recipient.

Same address

Subscriber Address *

Street Address

County

City State

Zip Code

I authorize payment from 3 Party Payer (Insurance) and Medicaid be made on my behalf to Pender County Health Department (PCHD) for services provided. I understand that my signature will serve as legal “signature on file” for purposes of filing Insurance/Medicaid claims and payment of benefits to the PCHD for services rendered. *

I authorize and understand

Signature of patient or authorized representative *

Clear

Date *

Date

I understand that I may access the Pender County Health Department Notice of Privacy Practices by visiting http://health.pendercountync.gov/ or I can request a copy from the front desk staff to address any concerns. *

I Understand

Signature of patient or authorized representative *

Clear

COVID 19 Patient and Admin Form

Vaccination Consent: