Stine's Apothecary Covid Vaccine Consent 4/2021

COVID-19 Immunization Consent Form
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*

FemaleMale
Patient Phone Number*
Race (select one)*

WhiteAfrican AmericanHispanicAsianAmerican IndianPacific IslanderOther
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Preferred Date and Time
Payment
Choose a payment method*

Commercial InsuranceMedicareI do not have insurance
Insurance Carrier
Medicare Number
Medicare Number (MBI) has 11 alphanumeric characters and can be found on your Red, White, and Blue Medicare Card.
Insurance ID Number
Rx BIN Number
Rx PCN
Rx Group
Please upload a photo of your PHARMACY and MEDICAL insurance card here. Front and back of card is needed.

Cancelof
Vaccine(s) to receive?*

Covid Vaccine - First doseCovid Vaccine - Second doseCovid Vaccine - Booster doseCovid Vaccine - 2nd Booster
If this is dose 2, what was the date of first dose

MonthDayYear
Date
Primary Care Provider (PCP) Name

First NameLast Name
Vaccine Screening Questions

Please complete the following questions.
Are you sick today?*

YesNo
Have you ever received a dose of the COVID-19 vaccine?*

YesNo
Have you ever had an allergic reaction to: a component of the COVID -19 vaccine including Polyethylene glycol, polysorbate, or a previous dose of COVID-19 vaccine?*

YesNo
Have you ever had an severe allergic reaction that required you to use an EpiPen (epinephrine) or required you to go to the hospital?*

YesNo
Have you received any vaccine in the last 14 days?*

YesNo
Have you ever had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?*

YesNo
Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?*

YesNo
Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?*

YesNo
Do you have a bleeding disorder or are you taking a blood thinner?*

YesNo
Are you pregnant or breastfeeding?*

YesNo
Consent to Vaccination

I have read, or have had read to me, the written information regarding the COVID-19 vaccine being administered. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine being administered and have received a copy of a current COVID Vaccine Fact Sheet. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Stines Apothecary, 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 certify that I am at least 18 years old and hereby give my consent to the pharmacists of this Pharmacy to administer the vaccine(s). If under 18 years old signature by parent or guardian is required. I agree to wait near the vaccination location for approximately 15 minutes for observation by the pharmacist.
Form completed by*

First NameLast Name
Signature of Person Receiving the Immunization (or Parent/Guardian of person < 18 years old)

Clear
Pharmacy Use Only

Do no complete the below questions
Signature of Pharmacist Administering

Clear
Name and Title of Immunization Administrator
Date Administered

MonthDayYear
Date Administered
Vaccine: Lot Number:
Administration Site: Deltoid (Left/Right)
Clinic notes (optional)
Should be Empty: