COVID Vaccine Consent Form

COVID-19 Vaccine/COVID TEST KIT Information and Consent Form

* Please fill out the required details below
BIVALENT BOOSTER VACCINES:

Pfizer & Moderna

ARE AVAILABLE

MONDAY-FRIDAY

NO APPOINTMENT NECESSARY

_________________________________________________________________

NO COST AT HOME COVID TEST KITS AVAILABLE

__________________________

VACCINE SCHEDULING PROCEDURE

If you would like to make an appointment for a COVID-19 Vaccine, please fill the information below and we will contact you with a same day or a next day appointment for your COVID-19 Vaccine.

Walk-Ins Also Welcome

Monday-Friday

Hazle Drugs is administering the following vaccines:
- Moderna
- Pfizer (Available for Ages 5 and Older)
MODERNA IS AVAILABLE TO THOSE INDIVIDUALS WHO ARE 18 YEARS OF AGE AND OLDER

PFIZER is available for ages 5 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:

MonthDay Year
Age:*
Phone Number:*
Email:*
Gender:*

MaleFemale
Address:*

Street Address Line 2
Primary Care Doctor:*
Doctor City/State:*
Would you like to receive NO COST COVID TEST KITS FREE for at home use? Medicare B beneficiaries as well as many other insurance plans will cover the tests for $0 (no cost to patient) and may receive up to 8 tests per person per month **PLEASE FILL OUT INSURANCE INFORMATION SECTION BELOW**

YES (Choose below how you would like your kits)PICK UP KITS IN STOREMAIL KITS TO HOME ADDRESSI WOULD ALSO LIKE TO RECEIVE COVID TEST KITS MONTHLYNO
Which of the following vaccines would you like to receive?

Moderna ( 2 shot series)Pfizer (5 years of age and older: 2 shot series)BIVALENT BOOSTER Moderna (18 years of age and older. Must be 2 months after your last vaccine)BIVALENT BOOSTER Pfizer (12 years of age and older. Must be 2 months after your last vaccine)
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 DoseBIVALENT BOOSTER DOSE *Must be 2 months after second dose of Moderna or Pfizer
If receiving your second dose, please indicate date of first dose

MonthDay Year
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:
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
INSURANCE INFORMATION:
Medicare Part B - Please submit this ID number even if you have a Medicare Advantage Plan! SEE EXAMPLE OF MEDICARE CARD ABOVE^
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

Cancelof
Please read*

I authorize the pharmacy to bill my insurance on my behalf for the immunization and/or No cost COVID test kits
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 NumberState identification number and state of issuanceDriver'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
Should be Empty:

COVID-19 Vaccine/COVID TEST KIT Information and Consent Form

INSURANCE INFORMATION: