Anderson Pharmacy Covid vaccine template Logo

  • COVID-19 Immunization Consent Form

    Please complete prior to arriving for your appointment

  • Payment

    There is no charge for the vaccine to you. By completing this form, you are providing consent for Anderson Pharmacy to bill your insurance for the administration of the COVID vaccine .
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  • Screening Questions:

    Please complete the following questions.

  • Consent to Vaccination

    I have read, or have had read to me, the written information regarding the COVID-19 vaccine being administered. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine being administered and have received a copy of a current COVID Vaccine Fact Sheet. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Anderson Pharmacy, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s). I certify that I am at least 18 years old and hereby give my consent to the pharmacists of this Pharmacy to administer the vaccine(s). If under 18 years old signature by parent or guardian is required. I agree to wait near the vaccination location for approximately 15 minutes for observation by the pharmacist. I have read and reviewed the Notice of Privacy Practices available at andersononmain.com
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  • Pharmacy Use Only

    Do no complete the below questions
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  • Moderna Vaccine: Lot Number: Expiration:
    Pfizer: Lot Number: Expiration:

    J&J: Lot Number: Expiration:

  • Administration Site: Deltoid (Left/Right)

  • Date Administered:
    Second dose due on (date): or N/A if this is second dose

  • Should be Empty: