Hague Pharmacy at CHKD
601 Children's Lane, Norfolk, VA 23507
COVID-19 Vaccination Form
This form is HIPAA Compliant & Secure!
PLEASE CHECK BACK TOMORROW MORNING 03/10/2021 AT 11:00 AM FOR APPOINTMENTS FOR THIS COMING WEEKEND 03/13/2021 & 03/14/2021 Saturday in Chesapeake, VA and Sunday in Norfolk, VA
Please only proceed if you are above the age of 65 or if you are a healthcare worker.
*
Healthcare Personnel (Please bring your work ID or Pay Stub)
Patient 65 years or older
Persons Age 16 - 64 with at least one high risk medical condition that the patient self-attests. Conditions listed are: Cancer, Chronic kidney disease, COPD (chronic obstructive pulmonary disease), Down Syndrome, Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies; Immunocompromised state (weakened immune system) from solid organ transplant; Obesity (body mass index [BMI] of 30 kg/m2 or higher but < 40 kg/m2); Severe Obesity (BMI ≥ 40 kg/m2); Pregnancy; Sickle cell disease; Smoking; Type 2 diabetes mellitus
COVID-19 Vaccine Consent Form
In order to receive the vaccine, you must be in the most appropriate phase of the vaccine rollout. Visit this link (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations.html) for more information at the federal level. States may have a different approach.
Select an appointment time
*
Vaccine Recipient Name
*
First Name
Middle Name
Last Name
Email
*
example@example.com
Vaccine Recipient Physical Address
*
Street Address
Street Address Line 2
City
State Initials
Postal / Zip Code
Date of Birth
*
/
Month
/
Day
Year
Gender at birth
*
Please Select
Male
Female
Race
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Ethnicity
*
Please Select
Hispanic or Latino
Not Hispanic or Latino
Unknown
Vaccine Recipient Phone Number
*
Format: (000) 000-0000.
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 a
component 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.)
Please Select
Moderna
Pfizer
Required if you selected "Yes" to #2
Date of first dose (do not complete if you selected "no" to #2 above.)
/
Month
/
Day
Year
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 Pfizer 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.
On Behalf of myself, my heirs and personal representatives, I hereby release and hold harmless Hague Pharmacy at CHKD, and their staff, volunteers, associates, successors, affiliates, subsidiaries, officers, directors, contractors, and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the vaccine listed above also I consent to use of Photography from the vaccination clinic if needed.
The vaccine is available to anyone no matter if insured or uninsured. Please check only one of the following.
*
Rows
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 Number
State identification number and state of issuance
Driver's license number and state of issuance
What Insurance do you have? If no insurance please select uninsured.
*
Please Select
Private
Medicare
Medicaid
Uninsured
Please take a Picture of your Driver License & Insurance Card including Medicare Card and Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):
VACCINE CLINIC LOCATION FOR SATURDAY 03/06/2021
*
Rows
Please Acknowledge
HINDU TEMPLE OF HAMPTON ROADS
217 SAMPSON CREEK ROAD,
CHESAPEAKE, VA 23322
Date Signed
/
Month
/
Day
Year
Date
Save
Submit Consent Form (required)
Should be Empty: