COVID Vaccine Consent Form

VACCINE SCHEDULING PROCEDURE

Registration for COVID-19 Vaccine is being done through this form.

Please fill the information below and we will contact you immediately with a same day or a next day appointment for your COVID-19 Vaccine.

HAZLE DRUGS IS CURRENTLY PROVIDING VACCINATIONS TO THOSE INDVIDUALS WHO ARE 18 YEARS OF AGE AND OLDER.

Please pick a day and time for your vaccination. PLEASE WRITE YOUR DATE AND TIME DOWN - YOU WILL ONLY RECEIVE AN EMAIL CONFIRMATION UPON COMPLETION IF YOU INSERT YOUR EMAIL ADDRESS AT THE BOTTOM OF THIS FORM *

Section I. Personal Information

Patient's Full Name: *

First Name Ml Last Name

Date of Birth: *

Age: *

Phone Number: *

Email: *

Gender: *

Male Female

Address: *

Street Address Line 2

Primary Care Doctor: *

Doctor City/State: *

Are you a current Hazle Drugs Pharmacy customer? *

YES, PLEASE FILL OUT QUESTION BELOW WITH RX NUMBER NO

PLEASE ENTER ANY ONE OF YOUR HAZLE DRUGS/HAZLE COMPOUNDING PRESCRIPTION NUMBERS FROM YOUR BOTTLE

RX NUMBER (JUST ENTER NUMBERS NO LETTERS)

Are you one of the following? Photo ID/Employment Verification Required *

Hazle Drugs is administering the MODERNA VACCINE and JANSSEN JOHNSON & JOHNSON VACCINE which are available for individuals 18 YEARS OF AGE AND OLDER

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

First Dose***Your appointment for your 2nd dose will be made in person at Hazle Drugs on the day of your appointment. PLEASE DO NOT SCHEDULE YOUR SECOND DOSE ONLINE*** Second Dose (When first dose was received elsewhere)

If receiving your second dose, please indicate date of first dose

Date

Section II. 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:
Do you feel sick today?

Do you carry an EpiPen?

Have you received COVID-19 monoclonal antibodies or convalescent plasma in the last 90 days?

Have you ever had a serious reaction or fainted after receiving any vaccination?

Have you ever had a seizure, brain disorder, or Guillain-Barre Syndrome?

For women: Are you pregnant or are you planning on becoming pregnant during the next month?

Do you have an allergy to any medications, foods or any vaccines?

Please specify the allergy:

**Vaccine supply is limited. Please keep your appointment when we contact you. If you miss your appointment, no doses of vaccine will be held for you.**

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

Medicare Part B - Please submit this ID number even if you have a Medicare Advantage Plan!

ID Number

Prescription Insurance-BIN NUMBER

(6 digits)

PCN

MEMBER ID NUMBER

RX GROUP

Please take or upload pictures of front & back of insurance card for billing purposes ***THIS IS NOT REQUIRED***

Browse Files

I authorize the pharmacy to bill my insurance on my behalf for the immunization

If uninsured, you must check the box below to attest that 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 health benefit plan

In order to have your vaccine administration fee paid for by the United States Health Resources & Services Administration's COVID-19 Program for uninsured patients, please select to provide one of the following: *

Social Security Number State identification number and state of issuance Driver's license number and state of issuance

Social Security Number *

State identification number and state of issuance *

Driver's license number and state of issuance *

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.

*** TO RECEIVE AN EMAIL CONFIRMATION OF YOUR FORM SUBMISSION PLEASE ENTER YOUR EMAIL ADDRESS IN THE BOX BELOW. THE EMAIL CONFIRMATION WILL BE FROM JOTFORM***

Email

example@example.com

COVID-19 Vaccine Information and Consent Form