COVID-19 Vaccine Consent Form
CURRENTLY WE ARE ADMINISTERING BOOSTER VACCINES FOR MODERNA AND PFIZER. PLEASE WALK-IN MONDAY-THURSDAY 10AM-6PM & FRIDAY 10AM-4:30PM. WE ARE NOT DOING APPOINTMENTS AT THE MOMENT AND ARE NOT VACCINATING ON WEEKENDS CURRENTLY. CALL 732-526-4450 WITH ANY QUESTIONS.
Are you 12 years of age and older?
Select an appointment time
Vaccine Recipient Name
Vaccine Recipient Physical Address
Date of Birth
Gender at birth
American Indian or Alaska Native
Black or African American
Native Hawaiian or Other Pacific Islander
Hispanic or Latino
Not Hispanic or Latino
Vaccine Recipient Phone Number
Primary Care Provider Name
Emergency Contact Name
Relationship to Emergency Contact
Phone Number of Emergency Contact
COVID-19 Vaccine Screen Questions
1. Are you feeling sick today?
2. In the last 10 days, have you had a COVID-19 test because you had symptoms and are still awaiting your test results or been told by a healthcare provider or health department to quarantine at home due to COVID-19 infection, exposure or travel??
3. Have you been treated with antibody therapy or convalescent plasma for COVID-19 in the past 90 days (3 months)?
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. Are you pregnant or considering becoming pregnant or breastfeeding?
7. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
8. Do you take any medications that affect your immune system, such as cortisone, prednisone, or other steroids, anticancer drugs, or have you had any radiation treatments?
9. Do you have a bleeding disorder or are you taking a blood thinner?
10. Have you had a previous dose of the COVID-19 vaccine?
Which arm would you like to get the injection on
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 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.
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.
Please Upload Insurance Card - *MEDICARE PATIENTS PLEASE UPLOAD THE RED, WHITE AND BLUE MEDICARE CARD*
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Choose a file
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
Please Upload Supporting Uninsured Document
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Choose a file
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):
Here at Pharmacy Emporium we offer free same day delivery for RX and OTC medications. Would you be interested in transferring you prescriptions to Pharmacy Emporium?
A pharmacist will gladly discuss the transfer process with you at the time of your appointment.
Submit Consent Form (required)
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