PLEASE READ -TO BE FILLED OUT AT APPOINTMENT
____I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet (insert link to EUA for the vaccine the pharmacy provides), 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 first dose of the COVID-19 vaccine, I intend to receive a second dose of the same vaccine in accordance with the timeframe specified in the Fact Sheet to complete the vaccination series.
____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.
____If insured, I authorize the pharmacy to bill my insurance on my behalf for the immunization – understanding I will not incur any costs.
If uninsured, you must initial 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 benefit plan.
For uninsured patients, please bring at least one of the following that you will bring with you to your appointment. This is needed in order to have your vaccine administration fee paid for by the United States Health Resources & Services Administration's COVID-19 Program.
Social Security Number
State identification number and state of issuance
Driver's license number and state of issuance