Your Choice Pharmacy

YOUR CHOICE PHARMACY & COMPOUNDING

Moderna and J & J COVID-19 Vaccine Consent Form Appointment slots will be available when we have the vaccine in stock Your submission of this form does not guarantee that you will get the vaccine as you have to be eligible, We follow strict guidance of CDC and State of FL. 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 at the federal level. States may have a different approach. Check FL Eligibility criteria at Home | Florida Department of Health COVID-19 Outbreak (floridahealthcovid19.gov)
Name

First Name Last Name
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Vaccine currently in stock: Moderna and J&J Covid-19 Vaccine
VACCINATION TYPE

MODERNA J & J
Vaccine Recipient Name *

First Name Last Name
Vaccine Recipient Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Appointment
Gender *
Date Of Birth *

Month Day Year
Date
Race *
Ethinicity *
Phone Number *
Please enter a valid phone number.
Mother's Maiden Name *
Required for vaccine documentation
Primary Care Provider Name
Emergency Contact Name *
Relationship to emergency contact *
Phone Number of Emergency Contact *
Please enter a valid phone number.
Email
example@example.com
For uninsured patients, please select at least one of the following that you will bring with you to your appointment.

Social Security Card State Identification Number and state of issuance Driver's License Number and State of issuance
Upload a picture of the front of pharmacy Insurance card, if Medicare use red, white and blue card. Uninsured patients please upload Social Security card or State id. *

Cancel of
Fill insurance information below or bring your card, Medicare red, white and blue card
Insurance company
Member ID
Medicare ID (red, white, blue card)
RX Group
RX BIN
RX PCN

COVID-19 Vaccine Screen Questions *

YES

1. Are you feeling sick today?

2. Have you ever received a dose of COVID-19 Vaccine?

3. Have you ever had an allergic reaction to (this includes a severe allergic reaction ie: Anaphylaxis, that require treatment with epinephrine "Epipen" ot that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.

3a. 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?

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?
(This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.)

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, venom, 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?

12. Do you have dermal fillers?

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 (the Janssen Covid Vaccine Fact Sheet is available after clicking submit), 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 understand that at this time, the COVID-19 vaccine may requires 2 doses given 21-28 days apart depending on the manufacturer. If this is my second dose, I will bring my vaccine card with me to be completed.

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. *

CHECK ONE

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.

Signature

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Date Signed

Month Day Year
Date
Appointment
Phone Number
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YOUR CHOICE PHARMACY & COMPOUNDING

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Fill insurance information below or bring your card, Medicare red, white and blue card