COVID-19 Consent & Appointment form

Patient Name *

First Name Last Name

Birth Date *

Date

Gender *

Patient Race *

White Black or African American Asian American Indian or Alaskan Native Other

Patient Ethnicity *

Hispanic or Latino Non Hispanic or Latino unknown

Mother's Maiden Name: *

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone *

Email - If you include your email address, you will be sent appointment reminders.

example@example.com

Patient Primary Care Provider *

Which vaccine would you prefer? (Pfizer is approved for 12yrs of age and older, Moderna is approved for 18 yrs of age and older) *

Pfizer Moderna

Have you ever received a dose of COVID-19 vaccine? *

Yes No

If yes, which vaccine did you receive?

Appointment Date and Time *

Appointment - Second Dose

Do you have (select one) *

Medicare Medicaid Private or Employer provided insurance No insurance

Medicare ID

Are you

Cardholder Spouse Child

RX BIN *

RX PCN *

ID # *

GROUP CODE

Social Security Number

Are you feeling sick today? *

Yes No

Have you ever had an allergic reaction to polysorbate, polyethylene glycol, or a previous dose of the COVID vaccine? *

Yes No

Have you ever had an allergic reaction that required treatment with epinephrine or caused you to go to the hospital? *

Yes No

Please list any additional allergies you may have.

Have you received any vaccine in the last 14 days? *

Yes No

If yes, please specify which vaccine you received.

Have you ever had a positive test or had a doctor tell you that you had COVID-19? *

Yes No

Have you received antibody treatment or plasma for COVID-19? *

Yes No Unknown

Do you have a weakened immune system or do you take immunosuppressive drugs or therapies? *

Yes No Unknown

Do you have a bleeding disorder or are you taking blood thinners? *

Yes No Unknown

Are you pregnant or breastfeeding? *

Yes No

I have read, or have had read to me, the COVID-19 EVA Fact Sheet. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine. I request that the vaccination be given to me (or to the person for whom I am authorized to make this request). I authorize this information to be forwarded to my primary care physician, authorizing physician, Iowa Immunization Registry Information System or local Department of Health if applicable. I agree to stay in the general area for 15 minutes after receiving the vaccination in case any immediate reactions occur. I understand that if I experience any side effects, it will be my responsibility to follow up with my physician at my expense. I hereby release Sergeant Bluff Pharmacy, Inc. and its employees from any and all liability that might arise from this vaccination on behalf of myself, my heirs, and my personal representatives. *

The information I provide, for myself or on behalf of whom I am authorized to provide information, is true to the best of my knowledge. I give consent to Sergeant Bluff Pharmacy and its staff for myself, and/or on behalf of whom I am authorized to give consent, to be vaccinated with vaccine/s and/or to receive other services provided by Sergeant Bluff Pharmacy.

By accepting this agreement, I consent and agree that use of a key pad, mouse or other device to select an item, button, icon or similar act or action while using any electronic service we offer or in accessing or making any transactions regarding any documents and disclosures constitutes my signature as if actually signed by me in writing (electronic signature). In some cases my electronic signature may be represented by my typed written name or initials electronically placed on the documents and disclosures by means of the process described herein. My electronic signature, whether expressed by process or symbolically or both, is hereby adopted by me and represents my intent to acknowledge receipt or sign, as applicable, the documents and disclosures and that my electronic signatures are thereby attached to, and logically associated with, the documents and disclosures. Further, I agree that no certification authority or other third party verification is necessary to the validity of my electronic signature and that the lack of such certification or third party verification will not in any way affect the enforceability of my signature or any resulting contract between myself and Sergeant Bluff Pharmacy. Withdrawing consent: I have the right to withdraw my consent and agreement to receive electronic documents and disclosures at any time. Because some documents and disclosures will be provided to me electronically, almost instantaneously once I have given my consent to do business with Sergeant Bluff Pharmacy electronically, I will not be able to withdraw my consent relating to the documents and disclosures I have already provided to Sergeant Bluff Pharmacy pursuant to that consent. However, I may withdraw my consent to receive subsequent documents and disclosures electronically, in which case Sergeant Bluff Pharmacy can deliver all subsequent documents and disclosures to me in paper form. I may withdraw my consent by contacting Sergeant Bluff Pharmacy at (712)943-1494. If I decide to withdraw my consent, the legal validity and enforceability of our prior electronic documents, disclosures and communications to me will not be affected. *

I accept the electronic signature consent I decline the electronic signature consent

By typing my name below, I accept the electronic signature consent *

Please read or print the EUA Fact Sheet before submitting your consent form.

Time

Hour Minutes

AM/PM Option

Sergeant Bluff Pharmacy COVID Vaccine Consent and Screening Form

Health and Screening Form

Clinical Service Consent Form

Consent to Electronic Signature