COVID 19 Vaccine Consent Form BOOSTER DOSE

COVID 19 Vaccine Consent Form BOOSTER DOSE
Have you had 1st COVID Vaccine? *

Yes No
If YES, which product? *
Date Administered? *

Month Day Year
Date
1st Dose given by Sumpter Pharmacy? *
This consent form is only for BOOSTER DOSES and only if 1st dose was given by Sumpter Pharmacy

Please return to the website to make the correct selection.
24 Days from Prime Dose:

Month Day Year
Date
LAST NAME *
FIRST NAME *
Middle Initial
Date of Birth *

Month Day Year
Date
Gender *
Cell Phone *
Please enter a valid phone number.
OK to Text? Y or N
*Required for Booster Reminders*
Address *

Street Address

Street Address Line 2

City State

Zip Code
Email Address
example@example.com
Race *
Ethnicity *
Allergies
Current Pharmacy
Mothers FIRST Name *
MEDICARE Number (new format required. If no Medicare, leave blank.
# = letters # = numbers
The following information should be found on your insurance card. Please bring your card with you to your appointment.
RxBIN
RxPCN
RxGROUP
ID or Member Number
Are you feeling sick today? *

Yes No
Have you ever had a severe allergic reaction to anything? *

Yes No
Do you carry an EpiPen? *

Yes No
Do you have a bleeding disorder or are you taking a blood thinner? *

Yes No
Have you had any other vaccine in the past 14 days *

Yes No
Are you pregnant or breastfeeding? *

Yes No
Have you received passive antibody therapy as a treatment for COVID-19? *

Yes No
If yes, has it been more than 90 days since your last treatment? *

Yes No
Signature *

Clear
License Plate
Vehicle Make/Model/Description
Select from Available Appointments. If none are visible there are no appointments available at this time. More appointments will open based on vaccine availability. Please check back at a later time. *
Appointment Date must be at least 24 days from initial dose.

Please select a different date/time.
Should be Empty:

COVID 19 Vaccine Consent Form BOOSTER DOSE

The following information should be found on your insurance card. Please bring your card with you to your appointment.