People's Pharmacy Vaccine Clinic

New Hope Church of God in Christ. 3241 Argonne AvenueNorfolk, Virginia 23509 Dr. Calvin Durham, Host

April 17, 2021 11:00 AM- 4:00 PM * Moderna Vaccine Clinic*
Appointment
General Information about person to receive vaccine | PLEASE FILL EVERYTHING
Name *
Sex *

Male Female
Birth date *

Month Day Year
Date
Age *
Race:

Asian Black Native American White Age:
Ethnicity:

Hispanic Non- Hispanic
Address *

Address

Street Address Line 2

City State

Zip
Phone Number *
Email *
example@example.com
Social Security Number
Do you have insurance *

Yes No
The following questions will help determine if there is any reason you should not receive a COVID immunization injection.
Do you have any chronic conditions? (Diabetes, high blood pressure, kidney disease, COPD, etc.)? *

No Yes Other
If Yes, list all
Are you a health care worker? Or can be considered as essential worker? *

Yes No
Do you live in a long-term care facility? *

Yes No
Facility Name
Is the person to be vaccinated sick in the past 14-30 days or today? *

Yes No
Is the person to be vaccinated ever received a COVID -19 vaccine? *

Yes No
If yes, Date

Month Day Year
Date
Type/Brand of COVID vaccine:
Does the person to be vaccinated have an allergy to any medications, food, vaccine, or latex? *

Yes No
List all allergies
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 *

Yes No
Have you ever had an allergic reaction to a Polysorbate or a previous COVID-19 Vaccine? *

Yes No
Has the person to be vaccinated ever had a severe reaction to any vaccine or injectable therapy *

Yes No
Are pregnant or breastfeeding? ☐ No ☐ Yes *

Yes No
Is the person to be vaccinated at least 18 years old? If no, how old?
Does the person to be vaccinated have a bleeding disorder or are they taking a blood thinner? *

Yes No
Has the person to be vaccinated received any vaccines in the past 14 days? *

Yes No
Has the person to be vaccinated ever tested positive for COVID-19? *

Yes No
Has the person to be vaccinated received passive antibody therapy as treatment for COVID-19? *

Yes No
I have read, or have had explained to me, the Emergency Use Authorization (EUA) for COVID-19 vaccine. I have had a chance to ask questions that were answered to my satisfaction. I believe I understand the benefits and risks of COVID-19 vaccine and ask that the vaccine be given to me or the person named above for whom I am authorized to make this request (parent or guardian) HAVE BEEN ADVISED TO WAIT FOR 15-30 MINUTES OF OBSERVATION AFTER RECEIVING MY VACCINE BEFORE LEAVING.
Print Parent/Guardian name, if different from client:
Signature *

Clear
Date *

Month Day Year
Date
INSURANCE INFORMATION
(Please give your insurance card to the receptionist)
Primary Insurance
Subscriber’s Name
Date of birth

Month Day Year
Date
Subscriber ID number
Group No
Group No
RX PCN
RX BIN
RX BIN
Secondary Insurance
Subscriber’s Name
Date of birth

Month Day Year
Date
Group No
Policy No
Client’s relationship to subscriber
Client’s relationship to subscriber:

The above information is true to the best of my knowledge. If qualified, I authorize billing to my insurance company and release of information required to process my claims.

I authorize my insurance benefits be paid directly to Peoples Pharmacy LLC.
Client Signature

Clear
Date

Month Day Year
Date
(01/2021 COVID-19 | Peoples Pharmacy)
Should be Empty:

New Hope Church of God in Christ. 3241 Argonne AvenueNorfolk, Virginia 23509 Dr. Calvin Durham, Host

INSURANCE INFORMATION