Parlin Pharmacy COVID-19 Vaccine Appointment Scheduling and Consent Form

MODERNA AND J&J COVID-19 Vaccine Consent Form (Must be 18 years or older)

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.
Are you at least 18 years old?*
Vaccine Site (Sayreville Police Department select 5/18/21 ONLY):*
Appointment time (Sayreville Police Department select 5/18/21 ONLY):*
NO APPOINTMENTS AVAILABLE? FILL OUT OUR WAITING LIST:
Vaccine Recipient Name (Please bring your ID at your scheduled vaccination)*

First NameMiddle NameLast Name
Email*
example@example.com
Vaccine Recipient Phone Number*
Vaccine Recipient Physical Address*

Street Address

Street Address Line 2

CityState

Zip Code
Date of Birth*

YearMonthDay
Gender at birth*
Race*
Ethnicity*
Have you in the past filled your prescriptions at Parlin Pharmacy?*
Primary Care Provider Name
Emergency Contact Name*
Relationship to Emergency Contact*
Phone Number of Emergency Contact*

COVID-19 Vaccine Screen Questions*

	Drop Down (Select One)
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. In the past 14 days, 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?

Have you received any COVID-19 VACCINE?
If you received your first COVID-19 Vaccine, please list manufacturer for the first dose received (do not complete if you did NOT receive the 1st vaccine.)
Required if you selected "Yes" to #2
Date of first dose (only if this will be your second vaccine)

MonthDayYear
Required if you selected "Yes" to #2

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 (Fact Sheet is available after clicking submit), a link to the Fact Sheet of which I was provided with this Consent Form. I have had a chance to ask questions that were answered to my satisfaction.
I understand that at this time, the Jansen requires only one vaccine COVID-19.
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.*

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.
OPTIONAL (YOU CAN UPLOAD YOUR INSURANCE CARD)

Cancelof
FOR INSURED PATIENTS:
(If you do not have this information at this time, please bring your card to the pharmacy on the day of the vaccine.)
Do you have Pharmacy Insurance:
Rx Insurance:   INSURANCE NAME
Rx Bin Number: RX BIN #
Rx PCN Number:  RX PCN #
Rx ID Number:   RX ID #
Rx Group Number:   RX GROUP
If you don't have this information at this point, we can also get it from your primary pharmacy. Please tell us the name and phone number of your pharmacy.
NAME OF PHARMACY   Area Code   Phone Number
For uninsured patients, please select at least one of the following that you bring with you to your appointment for verification.
Please type your social security number (MUST BRING COPY AT VACCINATION)*
State which issued your drivers license (Example: NJ, NY, PA)
Please type your drivers license number
YOU CAN TAKE A PICTURE OF YOUR ID (DRIVERS LICENSE) FOR FASTER PROCESSING. Otherwise you can bring your ID at your appointment.
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):

Clear
Date Signed

MonthDayYear
Date
Should be Empty:

MODERNA AND J&J COVID-19 Vaccine Consent Form (Must be 18 years or older)