COVID-19 Vaccine Appointment Scheduling

COVID-19 Vaccine Appointment and Consent
Please do not make multiple appointments

Please call us at (407) 898-1331 to reschedule or cancel an appointment, and for any questions regarding vaccine or booster eligibility. COVID-19 vaccines are free for everyone, regardless of insurance status. Help protect your community, your family, and yourself from COVID-19.

This form is for COVID-19 vaccines only. If you would like to schedule an appointment for a flu vaccine or any other vaccine, please click here.
Which COVID-19 vaccine would you like to receive?*
Note: As of August 31, 2022, the FDA has updated its emergency use authorization of COVID-19 booster doses to allow only for the use of "updated" bivalent vaccine products. All COVID-19 booster doses make use of this new bivalent version of the vaccine.
Please read the Janssen self attestation form below
Please indicate your reason for choosing the Janssen vaccine:

I am unable to take the Janssen vaccine due to a medical contraindication (Example: allergy to mRNA vaccine ingredients)I would otherwise remain unvaccinated if unable to take the Janssen vaccine
Select an appointment time*
Vaccine Recipient Name*

First NameMiddle NameLast Name
Vaccine Recipient Physical Address*

Street Address

Street Address Line 2

CityState Initials

Zip Code
Date of Birth*

MonthDayYear
Gender at birth*
Race*
This information is required by the state vaccine registry to help match patients to their records
Ethnicity*
Vaccine Recipient Phone Number*
Email*
A confirmation will be sent to this email with the time and date of your appointment
Emergency Contact Name*
Relationship to Emergency Contact*
Phone Number of Emergency Contact*
Are you insured, or uninsured?*

I am insured by a medical plan (e.g. Humana, Tricare, Medicare Part B)I am uninsured

	Check each box
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet, 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 agree to remain on the pharmacy premises for at least fifteen (15) minutes 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.
I understand that COVID-19 vaccines have different requirements for both timing and number of doses. I will follow up with the pharmacist or my healthcare provider if I am unsure or confused about vaccine requirements.

Insurance and ID Information
For insured patients please enter Member or Cardholder ID number and insurance company:

Medical ID numberCompany
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 issuanceOther
Take a photo of your Driver's License/Passport*
Please enter your License/Passport Number and Expiration Date*

License/Passport NumberExpiration Date
The insurance card you will bring is your MEDICAL insurance card, NOT prescription.

Example: the medical insurance card you would bring to the hospital or doctor's office.

Vaccine Fact Sheets

After reviewing the fact sheet for your chosen vaccine, please continue to the signature page.
Moderna 12+ Fact Sheet
Moderna 6-11 Fact Sheet
Pfizer 12+ Fact Sheet
Pfizer 5-11 Fact Sheet
Novavax 12+ Fact Sheet
Janssen 18+ Fact Sheet
V-Safe

COVID-19 Vaccine Consent Form
The COVID-19 vaccine will reduce the risk of suffering from the new type of Coronavirus disease, known as COVID-19.

Like any other vaccine, the COVID-19 vaccine is not 100% effective at preventing all illness caused by the COVID-19 virus. If you do get infected with the COVID-19 virus after receiving your vaccine, the illness will be less severe than if you had not been vaccinated. It can take a few weeks for your body to build up protection from the vaccine, and protection is most potent two weeks after receiving your last injection.

You are encouraged to follow the advice of your healthcare provider in considering further steps to reduce your risk of severe COVID-19. This is especially true for those at high-risk for developing severe disease, such as immunocompromised patients. Your doctor may recommend taking actions to reduce your chances of being exposed to COVID-19, such as masking and social distancing measures, and may recommend other injectable prophylactics such as monoclonal antibodies to give you the best protection.

As with other medications and vaccines, the COVID-19 vaccine has some side effects. The most likely side effects that you may experience from the vaccine include:
- Fever
- Pain at the injection site
- Redness and hardness of the skin at the injection site
- Headache
- Muscle aches or pain
- Joint aches or pain
- Fatigue (tiredness)
- Nausea/vomiting
- Chills
- Underarm gland swelling on the side of vaccination
Ask the pharmacist or immunizer for reccomendations on reducing and managing these side effects. If you develop any side effects not listed, or any that concern you, call the pharmacy or your doctor. If you are having an emergency, dial 911.
I authorize Orlando Pharmacy or its agents to submit a claim to my insurance provider or Medicare Part B without supplemental coverage payment for me for the above requested items and services. I assign and request payment of authorized benefits be made on my behalf to Orlando Pharmacy or its agents with respect to the above requested items and services.

By signing this form, I hereby attest that I have read and understood the acknowledgment letter and Emergency Use Authorization (EUA) for the vaccine product I chose provided above.

I declare and attest that the information I have provided above is correct.
Date

MonthDayYear
Date
Signature

Clear
Should be Empty:

	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 Appointment and Consent

Vaccine Screening Questions

Insurance and ID Information

The insurance card you will bring is your MEDICAL insurance card, NOT prescription.

Vaccine Fact Sheets

COVID-19 Vaccine Consent Form