Modena COVID-19 Vaccine Consent Form
In order to receive the vaccine, please answer all questions to the best of your knowledge. Please ready Covid Vaccine EUA document available at www.cdc.gov for detailed information, side effects etc on this vaccine. NEW OMICRON BIVALENT BOOSTER SHOT AVAILABLE NOW
Vaccine Location:
8324 US HWY 301 N,PARRISH, FL 34219
Do you qualify to receive the COVID-19 Vaccine as per latest FL State Guidance?
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Yes
No (Fill out the form and join our waitlist/standby) We will call contact you if available.
Select an appointment time
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Vaccine Recipient Name
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First Name
Middle Name
Last Name
Vaccine Recipient Physical Address
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Street Address
Apt #
City
State Initials
Zip Code
Date of Birth
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/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Gender at Birth
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Please Select
Male
Female
Race
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Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian
Other Pacific Islander
White
Other Asian
Other Non-White
Unknown
Ethnicity
*
Please Select
Hispanic or Latino
Not Hispanic or Latino
Unknown
Vaccine Recipient Phone Number
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Format: (000) 000-0000.
Primary Care Provider Name - Optional
Emergency Contact Name
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Relationship to Emergency Contact
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Please Select
Brother
Sister
Sibling
Mother
Parent
Father
Guardian
Spouse
Grandparent
Child
Foster child
Stepchild
Care Giver
Other
Phone Number of Emergency Contact
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Format: (000) 000-0000.
Email
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example@example.com
COVID-19 Vaccine Screen Questions
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Rows
Yes
No
1. Do you have today, or have you at any time in past 10 days a fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion, runny nose, nausea, vomiting or diarrhea?
2. Have you tested positive or have been diagnosed with COVID-19 in past 10 days?
3. Have you had severe allergic reaction (needed epipen or hospital care) to a previous dose of this vaccine or to any ingredients of this vaccine?
4. Have you had any other vaccinations in past 14 days
?
5. Have you had Covid-19 antibody therapy within the last 90 days? (e.g. Convalescent plasma)
6. Do yo carry epi-pen or emergency treatment of anaphylexis and/or have allergic reactions to any medication, food, latex etc?
7. For women, Are you pregnant or is there a chance you could become pregnant?
8. For women, Are you currently breastfeeding?
9. Are you immunocompromised or on a medication that may affect immune system?
10. Do you have a bleeding disorder or are you on blood thinner/blood thinning medications?
11. Did you receive previous dose of Covid-19 vaccine? If yes, please tell immunizer which manufacturer that was.
12. Are you current customer of Ellenton Discount Pharmacy?
13. Do you want Pharmacy staff to reach out to you about services we offer?
Which arm would you like to get the injection on
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Left Arm
Right Arm
Consent (check each box below after reading and prior to signing the form)
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Rows
Check each box
I certify that I am: (a) the patient and at least 16 years of age; (b) the legal guardian of the patient and confirm that the patient is at least 16
years of age; or (c) legally authorized to consent for vaccination for the patient named above. Further, I hereby give my consent to the Florida
Department of Health (DOH) or its agents to administer the COVID-19 vaccine.
I understand that this product has not been approved or licensed by FDA, but has been authorized for emergency use by FDA, under an EUA to
prevent Coronavirus Disease 2019 (COVID-19) for use in individuals either 16 years of age or older or 18 years of age and older; and the
emergency use of this product is only authorized for the duration of the declaration that circumstances exist justifying the authorization of
emergency use of the medical product under Section 564(b)(1) of the FD&C Act unless the declaration is terminated or authorization revoked
sooner.
I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccine(s). I understand the
risks and benefits associated with the above vaccine and have received, read and/or had explained to me the Emergency Use Authorization
Fact Sheet on the COVID-19 vaccine I have elected to receive. I also acknowledge that I have had a chance to ask questions and that such
questions were answered to my satisfaction.
I acknowledge that I have been advised to remain near the vaccination location for approximately 15 minutes (or more in specific cases) after
administration for observation. If I experience a severe reaction, I will call 9-1-1 or go to the nearest hospital.
On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless the State of Florida, the Florida Department of
Health (DOH), the Florida Division of Emergency Management (FDEM) and their staff, agents, successors, divisions, 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.
I acknowledge that: (a) I understand the purposes/benefits of Florida SHOTS, Florida’s immunization registry and (b) DOH will include my
personal immunization information in Florida SHOTS and my personal immunization information will be shared with the Centers for Disease
Control (CDC) or other federal agencies.
I further authorize DOH, FDEM, 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
DOH, FDEM, or its agents with respect to the above requested items and services. I understand that any payment for which I am financially
responsible is due at the time of service or if DOH invoices me after the time of service, upon receipt of such invoice.
I acknowledge receipt of the DOH Notice of Privacy Practices.
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.
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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
Please Upload Supporting Uninsured Document
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Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):
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Date Signed
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Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Pharmacist Name
First and Last Name
Pharmacist Signature
Lot Number
Vaccine Manufacturer
Expiration Date:
Pharmacy Name
Address
Pharmacy NPI
*
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