Moderna COVID Vaccine Consent Form

COVID Vaccine Consent Form - Rose Hill Pharmacy
Pharmacy will contact you once we receive your consent to schedule a vaccine date/time. Please make sure that the phone number listed is the number by which you would like to be contacted.

In order to receive the vaccine, you must be in the most appropriate phase of the vaccine rollout. Visit this link (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations.html) for more information at the federal level.
Section I. Personal Information
Patient's Full Name *

First Name Middle Name Last Name
Mother's Maiden Name *
Date of Birth: *

Month Day Year
Gender: *

Male Female
Email:
Phone Number: *
Address: *

Street Address Line 2
Race/Ethnicity: *

Caucasian African American Hispanic or Latino Asian American Indian Native Hawaiian/Other Pacific Islander Prefer not to answer
Primary Care Doctor *
Doctor Phone Number

Area Code Phone Number
Are you one of the following? *

Essential Worker (please bring badge/paystub/other proof of employment) First Responder (please bring badge/paystub/other proof of employment) Healthcare Worker (please bring badge/paystub/other proof of employment) Person with chronic condition (please bring evidence of condition or call ahead to have doctor verify) Employee of Rose Hill School District Resident of a care facility or other group setting Over age 65 Childcare providers and staff (licensed home childcare and childcare centers, preschool and afterschool programs) (please bring badge/paystub/other proof of employment) State and local government employees age 55-64 (please bring badge/paystub/other proof of employment) Utility workers age 55-64 (please bring badge/paystub/other proof of employment) No, I am not any of the above (please refrain from scheduling appointment until later phases)
What dose of COVID-19 vaccine will this be? *

First Dose Second Dose
When did you receive your first dose? *

Month Day Year
Date
Section II. Questionnaire for Immunization

Please select the correct option below: *

Yes

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 have an allergy to medications, foods, or any vaccines (eggs, gelatin, thimerosal, neomycin, gentamicin, latex, aluminum, preservatives, baker's yeast, etc.)?

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?

List Allergies:
**No patient will be billed for this COVID vaccination.** Insurance will be billed and will pay in full for insured patients. For uninsured patients, the federal government will be billed for the administration of COVID vaccines. Uninsured patients are asked to provide a DL or SSN for government billing purposes.
Type of Insurance Coverage:
Medicare Info:
Insurance Info:
Driver's License/State ID/SSN:
**Vaccine supply is limited. Please keep your appointment or call if you need to cancel or change it. Additionally, due to vaccine requirements; we may call you to see if you can come earlier, later or to a nearby location. If you miss an appointment, no doses will be held to guarantee your dose.**
Section IV. Signatures

I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (Moderna: https://www.modernatx.com/covid19vaccine-eua/eua-fact-sheet-recipients.pdf and Pfizer: https://www.fda.gov/media/144413/download ) a copy of which I was provided with this Consent and Release. 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 and Release.
I authorize the pharmacy to bill my insurance on my behalf for the immunization
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.
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COVID Vaccine Consent Form - Rose Hill Pharmacy