Moderna COVID Vaccine Consent Form

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: *

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

What dose of COVID-19 vaccine will this be? *

First Dose Second Dose

When did you receive your first dose? *

Date

Section II. Questionnaire for Immunization

Are you one of the following? *

age 18 and up (Moderna, Pfizer and J&J) age 12 and 17 (Pfizer)

Please select the correct option below: *

Yes

No

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.

My preferred vaccine is: *

Moderna (2 dose) Pfizer (2 dose) Janssen/J&J (1 dose) First available

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.

COVID Vaccine Consent Form - Rose Hill Pharmacy