COVID-19 Vaccine Appointment Scheduling and Consent Form

WE ARE ONLY OFFERING MODERNA VACCINE!
PLEASE SELECT THE VACCINE YOU ARE GETTING - ONLY FOR 04/24/2021
Please choose one

Virginia Phase 1B: Persons Age 16 - 64 with at least one high risk medical condition that the patient self-attests. Conditions listed are: Cancer, Chronic kidney disease, COPD (chronic obstructive pulmonary disease), Down Syndrome, Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies; Immunocompromised state (weakened immune system) from solid organ transplant; Obesity (body mass index [BMI] of 30 kg/m2 or higher but < 40 kg/m2); Severe Obesity (BMI ≥ 40 kg/m2); Pregnancy; Sickle cell disease; Smoking; Type 2 diabetes mellitus
COVID-19 Vaccine Consent Form

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.
Please select an appointment for MODERNA
Vaccine Recipient Name

FirstNameMiddle NameLastName
Email
example@example.com
Vaccine Recipient Physical Address

Street Address

CityState Initials

Zip Code
Date of Birth

MonthDayYear
Gender at birth
Race
Ethnicity
Vaccine Recipient Phone Number

Area CodePhone Number
Mother's Maiden Name
Required for proper vaccine documentation
Primary Care Provider Name
Emergency Contact Name
Relationship to Emergency Contact
Phone Number of Emergency Contact

Area CodePhone Number

COVID-19 Vaccine Screen Questions

Rows	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?

ONLY answer if you ALREADY received your first dose. COVID-19 vaccine manufacturer for the first dose you PREVIOUSLY received:
Required if you selected "Yes" to #2
ONLY answer if you ALREADY received your first dose. Date of first dose (do not complete if you selected "no" to #2 above.)

MonthDayYear
Required if you selected "Yes" to #2

Consent (check each box below after reading and prior to signing the form)

Rows	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 Pfizer/Moderna/J&J 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, some COVID-19 vaccine 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.
On Behalf of myself, my heirs and personal representatives, I hereby release and hold harmless Hague Pharmacy at CHKD, and their staff, associates, successors, 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 hereby acknowledge that the area where vaccination is administered maybe used to photograph and record video and film footage in connection with the promotional and publicity campaign of this and future vaccination site. By your presence in any of our vaccination facility, you acknowledge that you have read this and have been informed that you may be photographed and recorded as part of the release in video, photography and/or any media now known or hereafter devised, in perpetuity throughout the universe and publicity thereof. If you do not wish to be photographed or recorded please let us know immediately if you see any staff, media, or news channel recording you.

TO READ MORE ABOUT THE VACCINE PLEASE CLICK ON THE VACCINE NAME BELOW -

PFIZER EUA

JOHNSON & JOHNSON

MODERNA EUA

The vaccine is available to anyone no matter if insured or uninsured. Please check only one of the following.

Rows	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.

What insurance do you have? If no insurance please select uninsured.
For uninsured patients, please select at least one of the following that you will bring with you to your appointment.
Please take a Picture of your Driver License, Medicare Red White & Blue Card, and Insurance Card and Upload

Browse Files

Cancelof

VACCINE CLINIC LOCATION FOR SATURDAY

Rows	Please acknowledge
The Hope Center 1425 Gust Lane, Chesapeake, VA

Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):
Date Signed

MonthDayYear
Date

Pharmacy Use Only

Rows	1st Dose	2nd Dose	IM LEFT	IM Right
Pfizer Vaccine
Moderna Vaccine
Johnson & Johnson

Pharmacy Use Only - Date Shot Administered

MonthDayYear
Pharmacist Name
Signature
Should be Empty:

WE ARE ONLY OFFERING MODERNA VACCINE!

COVID-19 Vaccine Consent Form