COVID-19 Vaccine Appointment

Vaccine Recipient Name *

First Name Middle Name Last Name

Vaccine Recipient Physical Address *

Street Address

Street Address Line 2

City State Initials

Postal / Zip Code

Email (to receive notification of appointment and informational documents)

example@example.com

Date of Birth *

Gender at birth *

Insurance (The vaccine is available to anyone no matter if insured or uninsured.) *

	Yes	No
Do you have health or medical insurance (examples include Medicare, Medi-Cal, or private health policies)?

PRESCRIPTION INSURANCE PHONE #

Please enter a valid phone number.

BIN #

Please enter BIN #

PCN #

Please enter PCN #

ID #

Enter ID #

Group #

Enter Group #

MEDICARE ID #

Enter Medicare ID #

Vaccine Recipient Phone Number *

Primary Care Provider Name

If you would like to have a copy of this record sent to your Primary Care Provider, please provide name here.

Emergency Contact Name *

Relationship to Emergency Contact *

Phone Number of Emergency Contact *

COVID-19 Vaccine Manufacturer for the first dose received

COVID-19 Previous Dose *

	Yes	No
Have you ever received a dose of COVID-19 Vaccine?

Date of first dose of COVID-19 Vaccine

Previous COVID-19 vaccine dose

	Yes	No
Have you ever had an allergic reaction to a previous dose of COVID-19 Vaccine ?

COVID-19 Vaccine Screening Questions (If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just means additional information may be necessary before vaccination.) *

	Yes	No
1. 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?
2. Have you ever had an allergic reaction to Polysorbate?
3. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?
4. 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.
5. Have you received any vaccine in the last 14 days?
6. Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19?
7. 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]
8. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
9. Do you have a bleeding disorder or are you taking a blood thinner?
10. Are you pregnant or breastfeeding?

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 Moderna 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 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 acknowledge that my immunization information from this visit will be sent to the California Immunization Registry unless I choose to opt out.
I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Hendricks Pharmacy, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s).
I have read and reviewed the Notice of Privacy Practices available at www.HendricksPharmacy.flashrx.com.
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. Since you indicated you have insurance, please read and check this box.

	Check box
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.

The vaccine is available to anyone no matter if insured or uninsured. Since you indicated you do not have insurance, please read and check this box.

	Check box
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.

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

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

Clear

Date Signed

Date

Name

First Name Last Name

Please select appointments from Monday to Friday 10-am to 6 pm

Date

Time (Monday to Friday - 9:30 am - 6:45 pm | Saturday - 9:30 am - 2:45 pm

Hour Minutes

AM/PM Option

COVID-19 Vaccine Appointment and Consent Form