COVID-19 Vaccine Consent Form
In order to receive the vaccine, New York State is allowing Pharmacies to vaccinate individuals age 65 and older. Please fill out and print all forms ahead of your appointment. Please fill out the REQUIRED NEW YORK STATE COVID-19 VACCINE FORM at: forms.ny.gov/s3/vaccine Once this form is filled out, you will receive a SUBMISSION ID, please print and bring to your appointment. We will need proof of eligibility, you may bring a drivers license or passport with your date of birth on it. At your appointment we will schedule your second dose appointment, this will be 28 days after your first immunization. You will receive a vaccination card at your appointment and we will report your vaccination within 24 hours to the New York State Immunization Registry. Thank you for your assistance with these mandates. We are very happy to be able to support our community with administering the COVID-19 vaccine. You can support us by having all forms filled out ahead of your vaccination. We ask that you wear a short sleeve shirt to your appointment to make it easier for your immunization.
Select an appointment time
Vaccine Recipient Name
Vaccine Recipient Physical Address
Postal / Zip Code
Date of Birth
Gender at birth
American Indian or Alaska Native
Black or African American
Native Hawaiian or Other Pacific Islander
Hispanic or Latino
Not Hispanic or Latino
Vaccine Recipient Home Phone
Vaccine Recipient Mobile Phone
Mother's Maiden LAST Name
Required to ask for NY State Vaccine Documentaion on State Registry
Mothers Maiden FIRST name
Required to ask for NY State Vaccine Documentation on State Registry
Medicare ID Number (Red, White and Blue Paper Card)
Primary Care Provider Name
Emergency Contact Name
Relationship to Emergency Contact
Phone Number of Emergency Contact
COVID-19 Vaccine Screen Questions
1. Are you feeling sick today?
2. Have you ever received a dose of COVID-19 Vaccine?
3a. Have you ever had an allergic reaction to a
component of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures?
3b. Have you ever had an allergic reaction to
3c. Have you ever had an allergic reaction to a previous dose of COVID-19 Vaccine?
4. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?
5. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a component of COVID-19 vaccine, polysorbate, or any vaccine or injectable medication?
This would include food, pet, environmental, or oral medication allergies.
6. Have you received any vaccine in the last 14 days?
7. Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19?
8. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?
[note: monoclonal antibodies does not include antibiotics that you would be prescribed and filled at a pharmacy]
9. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
10. Do you have a bleeding disorder or are you taking a blood thinner?
11. Are you pregnant or breastfeeding?
COVID-19 Vaccine Manufacturer for the first dose received (do not complete if you selected "no" to #2 above.)
Required if you selected "Yes" to #2
Date of first dose (do not complete if you selected "no" to #2 above.)
Required if you selected "Yes" to #2
Consent (check each box below after reading and prior to signing the form)
Check each box
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet (the Fact Sheet is available after clicking submit), a copy of which I was provided with this Consent Form. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent Form.
I understand that at this time, the COVID-19 vaccine requires 2 doses given 21-28 days apart depending on the manufacturer. If this is my second dose, I will bring my vaccine card with me to be completed.
I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.
I understand that I will be receiving the vaccination at no cost to me.
The vaccine is available to anyone no matter if insured or uninsured. Please check only one of the following.
If INSURED, check this box attesting to bringing in your prescription and medical insurance cards for your vaccine appointment. By selecting this, you are also authorizing the pharmacy to bill your insurance on your behalf for the immunization – understanding you will not incur any costs.
If UNINSURED, you must check this box to attest that the 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 benefit plan.
For uninsured patients, please select at least one of the following that you will bring with you to your appointment.
Social Security Number
State identification number and state of issuance
Driver's license number and state of issuance
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):
Second Dose Scheduling Notification:
Maggy Pharmacy will schedule your second dose at the time of your first vaccination. Please be aware we do not have a lot of flexibility on the second dose scheduling. The second dose appointment is based on multiple factors including when we receive shipment of vaccine, vaccinators availability, access to volunteers and employees available for clinic, and the fact the all vaccine must be used within hours of opening vials to ensure no waste. We ask for your patience and ability to work with us if you decide to schedule an initial vaccine appointment. In the event we need to reschedule your second dose appointment you will be notified by email.
Submit Consent Form (required)
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