• COVID Vaccine Consent Form - Rose Hill Pharmacy

    Due to staffing issues we are currently not giving booster vaccines for Covid-19 for the next couple of weeks. Thank you for understanding. ( This note will be removed, when we are able to give vaccines again)
  • 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

  •  / /
    Pick a Date
  • Section II. Questionnaire for Immunization

  •  
  • **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.

  • **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.

  • 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.

  • Should be Empty: