COVID-19 Vaccine Appointment Scheduling and Consent Form

Vaccine Consent Form
Pfizer Bivalent vaccine now available!!

No appointments are required! Walk-ins are welcome!

Like Pineville Pharmacy on Facebook for more updates!
Please visit Find My Vaccine Group (nc.gov) to determine your COVID 19 vaccination eligibility

If you don't meet your state's eligibility criteria for a COVID 19 vaccination, you are not eligible to receive vaccination at this time. Modern and Janseen vaccine is approved for 18 years and older. Pfizer is the only vaccine approved for 16 years and older.
Which vaccine are you getting?

Pfizer for PediatricsPfizer BoosterModerna BoosterFlu Shot (2022-2023)Shingrix (Shingles)PneumoniaTetanus
I will be filling out this form with utmost INTEGRITY and I will provide TRUE and ACCURATE information to get vaccine. I have also checked NCDDHS website to determine my eligibility, and I am eligible to receive vaccine.*

I agree!
Select 1st dose/arm/vaccine

1st dose2nd doseIM-L ArmIM-R ArmModernaPfizer
Date of Administration 1st dose date
Lot Number 1st dose lot number
Expiration Date 1st dose exp date
Name of vaccine administrator
Select 2nd dose/arm/vaccine

1st dose2nd doseIM-L ArmIM-R ArmModernaPfizer
Date of Dose Admin   Date
Lot num lot number
Exp date  exp date
Name of vaccine admin
Do you currently live, work or volunteer full or part-time in any of the following?

GROUP-1. Health Care Settings ( including hospitals, outpatient clinics, COVID 19 Vaccination or testing sites, home health care, public health clinical services, emergency medical services, mortuaries, and pharmacies)GROUP-1. Long-Term Care Facilities ( including adult care homes, skilled nursing facilities, assisted living centers, group homes, continuing care reinternment communities, in-patient hospice facilities)GROUP-1: Home caregivers providing regular medical care to medically fragile children and adult (Visit NCDHHS website for more details)GROUP-2. Over the age of 65 years and olderGROUP-3. Work in person at Child Care or Pre-K to Grade 12 school  (including child care teachers and staff, school bus drivers, Pre-K-12 teachers, teacher assistants, food service, school maintenance and custodial staff, administrators, and other support staff)- (Frontline essential workers)GROUP-3. Work in person in either of these field - Critical manufacturing, higher education, essential goods, food and agriculture, government and community services, public health, public safety, transportation (Additional frontline essential workers)GROUP-4. Adults at high risk of exposure and increased risk of severe illness (Asthma, COPD, Diabetes type 1 or 2, high blood pressure, cancer, CKD, Cystic Fibrosis, liver disease, pulmonary fibrosis, overweight or obesity, pregnancy, history of stroke, heart conditions such as heart failure, CAD or cardiomyopathy, sickle cell disease, Intellectual and Development Disability, neurological condition, current or former smoker, etc.)Group- 5. Anyone over the age of 12 (Pfizer for 12 years and older; Janseen and Moderna for 18years and older)NONE OF THE ABOVE
Based on your responses, you are in Group 1. You are currently eligible to get a vaccine based on North Carolina’s COVID-19 Vaccination Plan.
Based on your responses, you are in Group 2. You are currently eligible to get a vaccine based on North Carolina’s COVID-19 Vaccination Plan.
Based on your responses, you are in Group 3. You are currently eligible to get a vaccine based on North Carolina’s COVID-19 Vaccination Plan.
Based on your responses, you are not yet eligible to get a vaccine based on North Carolina’s COVID-19 Vaccination Plan.
Appointment for shot*
Are you a current patient with Pineville Pharmacy?*

YesNo
I would like to transfer all my prescriptions to Pineville Pharmacy to save money and to receive better care. We are currently offering $25 store credit when you fill your transfer prescription with us.*

Yes (Thank you for the support. Pharmacy staff member will call you to get the details)No (I am not interested in free prescription delivery and personalized care by Pineville Pharmacy)
Vaccine Recipient Name*

First NameMiddle NameLast Name
Vaccine Recipient Physical Address*

Street Address

Street Address Line 2

CityState Initials

Zip Code
COUNTY
Date of Birth*

MonthDayYear
Gender at birth*
Race*
Ethnicity*
Vaccine Recipient Phone Number*
Email
example@example.com
Mother's Maiden Name
Required for proper vaccine documentation
Primary Care Provider Name
Phone Number of Emergency Contact
Do you have any underlying medication *
Are you *

COVID-19 Vaccine Screen Questions*

	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?

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

	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.

The vaccine is available to anyone no matter if insured or uninsured. Please check only one of the following.*

	Check one
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.

For uninsured patients, please select at least one of the following that you will bring with you to your appointment.

Social Security NumberState identification number and state of issuanceDriver's license number and state of issuance
Please upload following: insurance card (for insured patient) or government issued identification card (for uninsured patient)

Cancelof
Medicare Part B Number (Do not need to provide if you already uploaded a pic)
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):*

Powered by Jotform SignClear
Date Signed*

MonthDayYear
Date
1st shot paid/process

YesNoOther
2nd shot paid/process

YesNoOther
E-mail address
Should be Empty:

Vaccine Consent Form

Please visit Find My Vaccine Group (nc.gov) to determine your COVID 19 vaccination eligibility