Public Form - Paul Jones Drug - COVID-19 Vaccine Consent Form

COVID-19 Vaccine Consent Form
First, we need determine if you qualify. Please select an answer from the dropdown: Are you one of the following?*

We're sorry, at this time you do not qualify. Please check back later or follow the link below for more information on Covid-10 Vaccine Phases. Thank you.
Click Here: OKLAHOMA State Department of Health

or

Paul Jones Drug

COVID-19 Vaccine Consent Form
By providing your phone number, you are providing consent for Paul Jones Drug and our affiliates to contact you about your medications, refill reminders and other promotional activities using an automatic telephone dialing system or an artificial or pre-recorded voice/text message. You are not required to provide this consent as a condition to receive services or other products from us, and you can revoke this consent to any and all methods described above at any time. We may send text messages with security codes, alerts, notifications, refill reminders, links to download our app, and medication recalls. Message frequency varies depending on activity. You agree to receive SMS (Text) Messages to the number you provide below. MSG/Data rates may apply. You can always see the latest Terms of Use or Privacy Policy at https://www.pauljonesdrug.com
Congratulations, you qualify. Please complete the form below.
Select an appointment time
Enter in above scheduled date for printing.

MonthDayYear
Date
Enter in above scheduled time for printing

Hour Minutes

AM/PM Option
Status
Vaccine Recipient Name*

First NameMiddle NameLast Name
Vaccine Recipient Physical Address*

Street Address

Street Address Line 2

CityState Initials

Postal / Zip Code
Date of Birth*

MonthDayYear
Age
Gender at birth*
Race*
Ethnicity*
Cell Phone Number*
Format: (000) 000-0000.
Other Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Mother's Maiden Name*
Required for proper vaccine documentation
Primary Care Provider Name
Emergency Contact Name*
Relationship to Emergency Contact*
Phone Number of Emergency Contact*
Format: (000) 000-0000.

COVID-19 Vaccine Screen Questions*

Rows	Yes	No
1. Are you feeling sick today?
2. Have you ever received a dose of COVID-19 Vaccine?
3a. Have you ever had an allergic reaction to acomponent of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures?
3b. Have you ever had an allergic reaction to Polysorbate?
3c. Have you ever had an allergic reaction to a previous dose of COVID-19 Vaccine?
4. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?
5. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a component of COVID-19 vaccine, polysorbate, or any vaccine or injectable medication? This would include food, pet, environmental, or oral medication allergies.
6. Have you received any vaccine in the last 14 days?
7. Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19?
8. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? [note: monoclonal antibodies does not include antibiotics that you would be prescribed and filled at a pharmacy]
9. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
10. Do you have a bleeding disorder or are you taking a blood thinner?
11. Are you pregnant or breastfeeding?

COVID-19 Vaccine Manufacturer for the first dose received (do not complete if you selected "no" to #2 above.)
Required if you selected "Yes" to #2
Date of first dose (do not complete if you selected "no" to #2 above.)

MonthDayYear
Required if you selected "Yes" to #2

Consent (check each box below after reading and prior to signing the form)*

Rows	Check each box
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet (the Moderna Fact Sheet is available after clicking submit), a copy of which I was provided with this Consent Form. 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 Form.
I understand that at this time, the COVID-19 vaccine requires 2 doses given 21-28 days apart depending on the manufacturer. If this is my second dose, I will bring my vaccine card with me to be completed.
I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.
I understand that I will be receiving the vaccination at no cost to me.

If INSURED, check this box attesting to bringing in your prescription and medical insurance cards for your vaccine appointment. By selecting this, you are also authorizing the pharmacy to bill your insurance on your behalf for the immunization – understanding you will not incur any costs.If UNINSURED, you must check this box to attest that the the following information is true and accurate: I do not have any insurance, including but not limited to, Medicare, Medicaid, or any other private or government-funded benefit plan.
Social Security NumberState identification number and state of issuanceDriver's license number and state of issuance
(Front) Medicare A/B or Prescription Insurance Card image upload:
(Back) Medicare A/B or Prescription Insurance Card image upload:
Additional image upload:

Cancelof
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):
Date Signed

MonthDayYear
Date
By Submitting this form, you agree and consent to our Terms of Use and Privacy Policy.

Age label
Today

MonthDayYear
Date
AgeCalc
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COVID-19 Vaccine Consent Form

We're sorry, at this time you do not qualify. Please check back later or follow the link below for more information on Covid-10 Vaccine Phases. Thank you.

COVID-19 Vaccine Consent Form

Congratulations, you qualify. Please complete the form below.