COVID Vaccine Consent Form - MediLink RxCare

COVID-19 VACCINE APPOINTMENT REGISTRATION AND SCHEDULER
PLEASE SELECT THE VACCINE YOU WOULD LIKE TO RECEIVE BELOW

**SUBJECT TO AVAILABILITY**

WE OFFER THE FOLLOWING COVID-19 VACCINES:

BIVALENT BOOSTERS targeting Omicron variants. You can receive this booster if it has been at least 2 months since your last COVID-19 shot.

PLEASE NOTE: CHILDREN MUST BE OVER 30 LBS TO RECEIVE COVID-19 VACCINES AT MEDILINK RXCARE

We also offer the flu shot - no appointment necessary!

Your COVID-19 vaccine appointment will be at:

MediLink RxCare

44 South White Horse Pike

Hammonton, New Jersey 08037

If you have remaining questions, please call us at (609) 956-1900
Section I. Personal Information
Which COVID-19 vaccine do you wish to receive? PLEASE NOTE THIS IS SUBJECT TO AVAILABILITY AND MAY CHANGE.*

Pfizer Bivalent Booster (ages 6 mos - 4y - child must be over 30 pounds)Pfizer Bivalent Booster (ages 5 years +)Moderna Bivalent Booster (ages 6 mos - 5y - child must be over 30 pounds)Moderna Bivalent Booster (ages 6 years +)
Name of Person to Receive Vaccine:*

First NameMlLast Name
I am scheduling on behalf of:

MyselfMy childA person for whom I am Legal Guardian or Power of Attorney
Date of Birth:*

MonthDayYear
Phone Number:*
Email
example@example.com
Address:*

Street Address Line 2
Gender:*

FemaleMaleOtherUnknownNon-Binary
Race: (Please note the State of NJ requests this information to ensure equitable access to the vaccine)*

Black or African-AmericanAmerican Indian or Alaska NativeAsianWhiteNative Hawaiian or Other Pacific IslanderPrefer not to answerOther
Ethnicity: (Please note the State of NJ requests this information to ensure equitable access to the vaccine)*

Hispanic or LatinoNon HispanicPrefer not to specify
Which dose of the vaccine will this be?

Pfizer First DoseSecond DosePfizer or Moderna Booster DoseThird Moderna Dose (Available only to those who are immunocompromised)
Do you have any allergies?
If this is your third Moderna or Pfizer dose, when did you receive your second dose?

MonthDayYear
Section II. Appointment Scheduler
**Vaccine supply is limited. Please keep your appointment or call if you need to cancel or change it. Additionally, due to vaccine requirements, we may call you to see if you can come earlier, later or to a nearby location. If you miss an appointment, no doses will be held to guarantee your dose.**
Please pick a day and time for your vaccination*
Section III. Insurance Information

Please note - insurance is not required to receive a COVID-19 vaccine.
Who is your health insurance provider? If uninsured, type "uninsured."
Please type your health insurance or Medicare ID number. If uninsured, type "uninsured." If you have Medicare, please type your Medicare ID number found on your "red, white and blue" card.
Insurance*

I authorize the pharmacy to bill my insurance, if I have insurance, on my behalf for administration of the immunization. I understand that the pharmacy will not bill my insurance for the vaccine itself, only for the administration of the vaccine. I understand that I, as the patient, will not be billed for administration or the vaccine.
If uninsured, you must check the box below to attest that 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 health benefit planI currently have insurance coverage
Covid-19 Vaccination Consent*

I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) or Fact Sheet, a copy of which I was provided with this 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 or ward for who I legally represent that I am authorized to sign this Consent and Release.
Moderna Pediatric COVID-19 EUA Vaccine Fact Sheet (ages 6m-5y)
Moderna Pediatric COVID-19 EUA Fact Sheet Bivalent Booster (ages 6m-5y)
Moderna Pediatric COVID-19 EUA Vaccine Fact Sheet (ages 6y-11y)
Moderna "Spikevax" COVID-19 Vaccine Fact Sheet (ages 12+)
Moderna COVID-19 Vaccine Fact Sheet Bivalent Booster (ages 6+)
Pediatric Pfizer/BioNTech COVID-19 Vaccine EUA Fact Sheet (ages 6m-4y)
Pediatric Pfizer/BioNTech COVID-19 Vaccine EUA Fact Sheet Bivalent Booster (ages 5-11)
Pediatric Pfizer/BioNTech COVID-19 Vaccine EUA Fact Sheet (ages 5-11)
Pfizer/BioNTech "Comirnaty" COVID-19 Vaccine Fact Sheet (ages 12+)
Pfizer/BioNTech COVID-19 Vaccine Bivalent Booster Fact Sheet (ages 12+)
Janssen/J&J COVID-19 Vaccine EUA Fact Sheet (ages 18+)
Novavax COVID-19 Vaccine EUA Fact Sheet (ages 12+)
I understand that the pharmacy cannot guarantee that a vaccine dose will be available on the date and time that I scheduled my appointment.

Our staff will be in contact should changes need to be made.

By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.
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COVID-19 VACCINE APPOINTMENT REGISTRATION AND SCHEDULER