• Janssen (J&J) COVID-19 Vaccination Consent Form

    (410) 526-1055 www.finksburgpharmacy.com

  • IMPORTANT

    **New October 21, 2021**

    After receiving your 1st dose of JANSSEN (J&J) COVID-19 VACCINE:
    ALL individuals may receive a 2nd dose booster vaccination two months after your first dose.  

    **New December 16, 2021**  

    THIS FORM IS FOR INITIAL FIRST DOSES ONLY.  DO NOT FILL OUT THIS FORM FOR A JANSSEN (J&J) BOOSTER.

    In conjunction with the ACIP and CDC recommendations, we will no longer be providing Janssen (J&J) booster vaccinations.  If you received an initial single dose series of a Janssen (J&J) COVID-19 vaccine, and would like to sign up for a booster vaccination, please exit this form and select either the Moderna or Pfizer form to reserve your date and time.

    For more information about this recommendation, please CLICK HERE

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  • Screening Questions

    The following questions will help us determine if there is any reason you should NOT get the COVID-19 vaccine today. If you answer "YES" to any question, it does not necessarily mean you should not be vaccinated. It means additional questions may be asked. If a question is not clear, please ask your healthcare provider to explain it.

  • Finksburg Pharmacy is only providing the initial series Janssen (J&J) COVID-19 vaccine.  

    In conjunction with the ACIP and CDC recommendations released on December 16, 2021, we will no longer be providing Janssen (J&J) booster vaccinations.  If you received an initial single dose series of a Janssen (J&J) COVID-19 vaccine, and would like to sign up for a booster vaccination, please exit this form and select either the Moderna or Pfizer form to reserve your date and time for an mRNA booster.  

    For more information, please CLICK HERE

  • The vaccine is being provided at no cost by the government. Your insurance will be charged for the costs of administering the vaccine.

  • Private Insurance Information:
                         
    RX BIN #   *   
    RX PCN #  *   
    RX Group #   *   
    RX ID #   *   

  • Medicare ID #   *   
    *Note: This is your NEW Medicare Unique ID number.
    Last 4 digits of Social Security Number (for Medicare ID verification) *   

  • Medical Assistance # (11 digits long):   *   

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  • CONSENT

  • *Persons who have had a severe reaction to a vaccine or currently have an acute febrile illness should not receive a vaccine. I certify that all information provided on this form is correct. I consent to the staff to administer the vaccination(s) mentioned below. I understand that this vaccine has been authorized by the FDA under an Emergency Use Authorization and I have reviewed the fact sheet that has been provided to me concerning the specific manufacturer of the vaccine I am receiving today. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of receiving this vaccine and choose to assume this risk. I fully release and discharge the pharmacist and the pharmacy, its affiliations and their officers and employees from any illness, injury, loss, or damage that may result there from. I acknowledge that I have received a copy of the pharmacy's privacy policies according to HIPAA. I assign payment of authorized insurance benefits due to me to be paid to the pharmacy. I consent the release of medical information when necessary for billing, reimbursement, and medical protocol. I also allow for the pharmacy to report any vaccinations received to the appropriate state vaccine registry. I am aware that an immunization certified student pharmacist might be administering this vaccine. I understand that COVID-19 vaccination doses are limited, and if I miss my appointment, I am NOT guaranteed a vaccination at another time. I agree to wait near the vaccination area for a minimum of 15 minutes or as otherwise instructed by the pharmacist so that I may receive treatment if I begin to feel unwell.
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  • Please bring your Driver's License (or other form of valid photo ID) to your appointment for proof of identity.

  • **For Clinic Use Only**

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