COVID Vaccine Consent Form

Section IV. Signatures/Firmas:

I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA), 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.

Yo entiendo los beneficios/riesgo de la vacuna de COVID-19 como descritos en la Autorización de Uso de Emergencia (EUA Español), la cual recibí una copia con este consentimiento y forma de liberación. He tenido la oportunidad de hacer preguntas que han sido contestadas a mi satisfaccion. Solicito que administren la vacuna a mi o la persona nombrada arriba.
Signature of Person to Receive Vaccine & EUA/VIS or Signature of parent/guardian: Firma de persona recibiendo vacuna y EUA/VIS o Firma de padre/guardián: *

Clear
I have received a copy of the notice of Privacy Practices. I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.

He recibido una copia de Aviso de Prácticas de Privacidad. Yo entiendo que el aviso de Prácticas de Privacidad explican las formas en que mi información medica va a ser utilizada o divulgada por la farmacia y mis derechos respecto a mi información médica. He tenido la oportunidinad de discutir preguntas sobre la privacidad de mi información médica.
Signature of Acknowledgment of Notice of Privacy Practices: Firma de Reconocimiento del Aviso de Prácticas de Privacidad: *

Clear
Select the option that applies/ Seleccione la opcion que aplica:*

I have Medical Insurace (Private/Medicaid/Medicare/other) / Tengo Seguro medico(Privado/Medicare/Medicaid/otro)I do not have Medical Insurance/ No tengo seguro medico
Please upload picture of front & back of insurance card for billing purposes: Por favor tome una foto de su tarjeta de aseguranza de atras y adelante:

*Bring card to your appointment if unable to upload/Traer a su cita si no puede subir foto
Cancelof
Provide Information on Member card if unable to upload (ID#, RxGroup#, BIN# or Social Security Number)/Provee informacion en la tarjeta medica si no puede proveer copia de la tarjeta (Numero de identification, grupo Rx, BIN o numero social)
Check the box below to attest that the following information is true and accurate Seleccione la casilla para dar fe que la información dada es verdadera y correcta

I do NOT have any insurance, including but not limited to Medicare, Medicaid or any other private or government-funded health benefit plan NO tengo seguro médico (no tengo Medicare, Medicaid, seguro médico privado u otro beneficio médico financiado por el gobierno)
In order to have your vaccine administration fee paid for by the United States Health Resources & Services Administration's COVID-19 Program for uninsured patients, please select to provide one of the following: Para que el Programa de los Estos Unidos de Recursos y Servicios de Administracion page la administracion de la vacuna del COVID-19, necesita proveer uno de los siguientes:*

Social Security Number/ Número SocialDriver's license number and state of issuance/Número de LicenciaValid state ID number and state of issuance/ Otra identificación valida
Social Security Number/Numero Social
Driver's License Number and State of Issuance/Numero de Licencia y Estado
Number of Valid Form of ID / Numero de Identificacion Valida y Estado:
Insurance Billing Authorization/Autorización de Cobro:*

I authorize Pronto Pharmacy to bill my insurance or the Federal Vaccination Program for the immunization / Yo autorizo a Pronto Pharmacy a facturar a mi seguro médico o Programa Federal de Vacunas por la imunización.
**Vaccine supply is limited. You will receive a link to your email to make the appointment once the vaccine is available at the pharmacy. Please do not miss your appointment. Due to vaccine requirements; we may call you to see if you can come earlier, later or another date. If you miss an appointment, no doses can be held**

**La cantidad de vacuna disponible es limitada. Recibira un enlace en su correo electronico para hacer su cita una vez que la vacuna este disponible. Favor de venir a su cita a tiempo. Debido a requisitos de la vacuna, tal vez le llamaremos para pedirle que venga mas temprano, mas tarde u otra fecha. Si pierde su cita, no podemos guardarsela**
Should be Empty:

	Yes/Si	No	Don't know/ No sé
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? ¿En las últimas 2 semanas, ha salido positivo de COVID-19 o esta actualmente siendo monitoreado de COVID-19?
In the past two weeks, have you had a known exposure with anyone who tested positive for COVID-19? ¿En las últimas 2 semanas, ha sido expuesto a alguien que salió positivo al COVID-19?
In the past 14 days, 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? En los últimos 14 dias, a tenido síntomas de fiebre, resfrios, tos, falta de respiración, dificultad al respirar, fatiga, dolores musculares, dolor de cabeza, perdida del sentido del olfato o gusto, dolor de garganta, nausea, vomito, o diarrea
Questionnaire for Immunization: Do you feel sick today? ¿Se siente enfermo hoy?
Have you ever had an allergic reaction to: -A previous dose of COVID-19 vaccine? -A component of COVID-19 Vaccine (polyethylene glycol) -Polysorbate Ha tenido una reacción alérgica a: -Dosis previa de la vacuna de COVID-19 -Componenetes de la vacuna de COVID-19 (polietilenglicol), -Polisorbato
Have you ever had a serious reaction or fainted after receiving any vaccination? Ha tenido alguna reacción seria o se ha desmayado despues de una vacunación?
Have you ever had a seizure, brain disorder, or Guillain-Barre Syndrome? ¿Ha tenido convulsiones, trastorno cerebral, o síndrome de Guillaine-Barré?
For women: Are you pregnant or are you planning on becoming pregnant during the next month? ¿Está embarazada o planea embarazarse en en siguiente mes?
Do you have an allergy to medications, foods, or any vaccines (eggs, gelatin, thimerosal, neomycin, gentamicin, latex, aluminum, preservatives, baker's yeast, etc.)? ¿Tiene alergias a algun medicamento, comidas, vacunas (huevos, gelatinas, timerosal, neomicina, gentamicina, látex, aluminio, conservantes, levadura, etc.?
Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication? ¿Ha tenido alguna reacción alérgica a alguna otra vacuna (a parte de vacuna de COVID-19) o medicamento inyectable?
Have you received COVID-19 monoclonal antibodies or convalescent plasma in the last 90 days? ¿Ha recibido anticuerpos monoclonicos de COVID-19 o plasma de convalecencia en los últimos 90 dias?
Do you have a weakened immune system? ¿Tiene un sistema inmune débil?
Do you have a bleeding disorder or taking blood thinners? ¿Tiene algun trastorno hemorrágico o toma anticoagulantes?
Have you received a passive antibody therapy as treatment for COVID-19? ¿Ha recibido tratamiento de anticuerpos pasivo como tratamiento para COVID-19?