COVID Vaccine Consent Form

We are required to maintain a 2nd dose standby list to ensure no COVID vaccine doses are wasted.

This does not guarantee a spot in an upcoming clinic. We are simply capturing your information and will reach out if/when we have Second Doses available.

If you have remaining questions, please email our Vaccine Support: vaccine@drnealsmoller.com.

HERE IS THE CRITERIA FOR THIS STANDBY LIST AS OF 3/2021:

SECOND DOSE ONLY
MODERNA VACCINE
IMMUNIZED RECENTLY

You can get your second dose 2 days before and up to 2 weeks after your due date.

We will only contact people who are eligible when we have Second Doses available.

Please enter your Date of Birth*

Date

FirstSecond

YesNo

You are not eligible for this clinic.

This clinic is for the SECOND dose of MODERNA vaccine who have not been treated with COVID antibodies in the last 90 days or have not had any other vaccine within 14 days.

We prefer patients over 65, but will capture names of eligible SECOND DOSES for other priority groups.

Section I. Personal Information

Date You Received Your First Dose

Date

Patient First Name*

Patient Last Name*

MaleFemaleOther

Phone Number:*

Email:*

Address:*

Street Address Line 2

Primary Care Doctor:*

Doctor City/State:*

Please enter any and all drug or food allergies:

Section II. Questionnaire for Immunization

Please select the correct option below:*

Rows	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: 1. Do you feel sick today?
2. Have you ever had a serious or life-threatening allergic reaction (hives, difficulty breathing) to any vaccine or shot?
3. Do you carry an EpiPen?
4. Have you received COVID-19 monoclonal antibodies or convalescent plasma in the last 90 days? YOU ARE NOT ELIGIBLE IF THIS ANSWER IS YES!
5. Have you had any OTHER vaccines in the past 14 days? PLEASE WAIT 14 DAYS AFTER ANY OTHER IMMUNIZATION BEFORE GETTING COVID VACCINE!

Section III. Signatures

In an attempt to reduce paper waste, all legally required documents must be downloaded here. Very limited copies will be available on clinic day.

Click this to download the Emergency Use Authorization for the Moderna Vaccine.

Click this to download the Notice of Privacy Practices

Click this to download the CDC vSafe app flyer

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 registration.

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.

I certify that I have received, read, and understand the Emergency Use Authorization.

I certifty that I have received the Notice of Privacy Practices.

I certify that I have received the CDC vSafe informational flyer.

Please type your full name in the box below. You agree your typed full name represents your electronic signature is the legal equivalent of your manual signature on this form.

Type Your Full Name as Electronic Signature*

I authorize the pharmacy to bill my insurance on my behalf for the immunization

I do not have any insurance, including but not limited to Medicare, Medicaid or any other private or government-funded health benefit plan

Social Security NumberState identification number and state of issuanceDriver's license number and state of issuance

Social Security Number*

State identification number and state of issuance*

Driver's license number and state of issuance*

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 Second Dose Standby

Section I. Personal Information

Section II. Questionnaire for Immunization

Section III. Signatures