COVID Vaccine Consent Form

COVID Vaccine Consent Form - Medicap VA Ave

* Please fill out the required details below
If you are 65 or older you automatically qualify to receive a COVID-19 vaccine from Medicap Pharmacy. If you are ages 18-64 the health conditions in the chart below will qualify you to receive a COVID-19 vaccine at Medicap Pharmacy without a prescription from your physician. If you do not have one of these conditions you will need to contact your physician for a prescription. We can only vaccinate anyone under the age of 18 with a prescription from your provider and do not vaccinate anyone under the age of 12 for COVID-19.
- You are signing up for a MODERNA COVID-19 mNEXSPIKE 2025-2026 VACCINE. For information on this vaccine click the image above to be directed to the Vaccine Information Statement.
**Please keep your appointment or call if you need to cancel or change it. If you miss an appointment, no doses will be held to guarantee your dose.**
mNEXSPIKE is a vaccine to protect against COVID-19. This form is ONLY for persons who are 65 years of age and older, or 18 years through 64 years of age AND at high risk for severe COVID-19. By selecting below, I understand and verify that I meet one of the following conditions.*

I am 65 years of age or older.I am 18-64 years old AND at high risk for severe COVID-19 with at least one condition from the chart above (Virginia Protocol currently requires a prescription from a physician for under 18 years of age)
Appointment Date and Times listed below. Only dates and times listed in blue are available to be selected. If all times are listed in gray then none are currently available. Check back at a later time as it will be updated daily.*
Section I. Personal Information
Patient's Full Name:*

First NameMlLast Name
Date of Birth:*

MonthDayYear
Age:*
Phone Number:*
Gender:*

MaleFemale
Ethnicity:*

Hispanic or LatinoNon Hispanic/LatinoUnknownPrefer not to answer
Race:*

Black or African AmericanAmerican Indian or Alaska nativeAsianWhiteNative Hawaiian/Other Pacific IslanderPrefer not to answerOther
Email
example@example.com
Address:*

Street Address Line 2
Primary Care Doctor:
Doctor City/State:
Section II. Questionnaire for Immunization

Please select the correct option below:*

	Yes	No	Don't know or N/A
Do you feel sick today?
Have you ever had an allergic reaction to a previous dose of COVID-19 vaccine?
Have you ever had an allergic reaction to another vaccine or injectable medication?
Have you ever had a severe allergic reaction to something other than a component of Covid-19 Vaccine, or any vaccine or injectable medication?
Do you have a history of myocarditis or pericarditis within 3 weeks after any dose of any COVID-19 vaccine?
Have you had a positive test for COVID-19 or has a doctor told you that you had COVID-19 in the last 90 days?
Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
Do you have a history of Multisystem Inflammatory Syndrome (MIS-C or MIS-A)?
Are you pregnant or breastfeeding?

Please list severe allergies
Section III Signatures

I understand the benefits and risks of the COVID-19 vaccine as described in the Vaccine Information Statement (VIS), a copy of which I viewed by clicking on the image above of the vaccine I wish to receive. 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 and Release.
Signature of Person to Receive Vaccine & VIS *

Clear
I have received a copy of the notice of privacy practices Click here for Privacy Practices. 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.
Signature of Acknowledgment of Notice of Privacy Practices:*

Clear
I authorize the pharmacy to bill my insurance on my behalf for the immunization
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.
Vaccine Date Administered Vaccine Lot Exp Dosage Injection site

__/__/2025 0.5ml R / L Arm

Signature: _____________________________________________________________
Should be Empty:

COVID Vaccine Consent Form - Medicap VA Ave