Hope Pharmacy COVID-19 Vaccine Registration Form

Hope Pharmacy COVID-19 Vaccine Form

If completing for others, please enter information for each patient.
Appointment*
This is my First, Second, or Third dose of the COVID-19 Vaccine:*

First DoseSecond DoseBooster
Which vaccine are you requesting*

Pfizer (All doses 12+)Pfizer Pediatric (All doses 5-11)Moderna (All doses 18+)Janssen (All doses 18+)
Salutation
First Name*
Middle Name
Last Name*
Date of Birth *

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
By completing these fields you are attesting that you are 5+ years of age or older?*

I am 5-11 years of ageI am 12 years of ageI am 13-17I am 18+
What COUNTY do you live in?*
Parent or Legal Guardian Name (Only applicable if patient is 18 years of age or younger)

First NameLast Name
Parent or Legal Guardian Date of Birth (Only applicable if patient is 18 years of age or younger)

MonthDayYear
Date
Are you someone that (please check all that apply)*

served in the U.S. militaryis a spouse or a surviving spouse of a Veteranis a caregiver of a Veteranis receiving the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) benefitsis employed by the U.S. Department of Veterans Affairs, Department of Homeland Security, General Services Administration, Food and Drug Administration, National Archives and Records Administration, or Federal JudiciaryNone
Please review and check ALL the boxes below*

Please bring your ID and insurance card with you to your appointment.Please arrive as close to your appointment time as possible to prevent traffic congestion.Please allow 30 minutes upon arrival. You will be required to remain on site for 15 minutes for observation. Additional instructions will be provided upon arrival.If the patient is 17 years of age or less, a parent or legal guardian must accompany the patient during the vaccine process. If readily accessible, please bring the child's ID or birth certificate.
People younger than 18 years must have parental or guardian consent, unless patient is an emancipated minor. Learn more.
Health Insurance
Health Insurance - Do you have health coverage? The COVID-19 vaccine is free for everyone. Health insurance is not required. If you do not have health coverage, select No. If you do have health coverage, select Yes and your insurance will pay the vaccine provider for administering the vaccine- at no cost to you. You will not be charged or billed by your insurance.*

Yes, I have health insuranceNo, I do not have health insurance
COVID-19 Vaccine related information
Are you feeling sick today?*

YesNo
Have you been diagnosed with Multisystem Inflammatory Syndrome (MIS-C orMIS-A) after a COVID-19 infection?*

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

YesNo
Allergic reaction information
Have you ever had an allergic reaction to (1) component of the COVID-19vaccine, including polyethylene glycol (PEG), which is found in somemedications, such as laxatives and preparations for colonoscopy procedures, (2)Polysorbate, (3) a previous dose of COVID-19 vaccine (This would include asevere allergic reaction (e.g., anaphylaxis) that required treatment withepinephrine or EpiPen® or that caused you to go to the hospital. It would alsoinclude an allergic reaction that occurred within 4 hours that caused hives,swelling, or respiratory distress, including wheezing.)*

YesNo
Have you ever had an allergic reaction to another vaccine (other than COVID-19vaccine) or an injectable medication? (This would include a severe allergicreaction (e.g., anaphylaxis) that required treatment with epinephrine or EpiPen®or that caused you to go to the hospital. It would also include an allergic reactionthat occurred within 4 hours that caused hives, swelling, or respiratory distress,including wheezing.)*

YesNo
Have you ever had a severe allergic reaction (e.g., anaphylaxis) to somethingother than a component of the COVID-19 vaccine, polysorbate, or any vaccine orinjectable medication? This would include food, pet, environmental, or oralmedication allergies.*

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

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

YesNo
Do you have a history of heparin-induced thrombocytopenia (HIT)?*

YesNo
Are you pregnant or breastfeeding?*

YesNo
Have you received dermal fillers?*

YesNo
Do you have a history of myocarditis or pericarditis?*

YesNo
ADA Requirements
State and federal nondiscrimination laws require medical providers to make sure that people with disabilities have the same access to medical care as people without disabilities. Please let us know if you require one or more of the following accommodations at your vaccine appointment. Check as many as apply.*

I do not require any accommodation during my appointmentI require a companion or supporter to accompany meI require a service animal to accompany meI require extra time for my appointmentI require assistance with reading orcompleting paperworkI require a qualified sign language interpreterI require an assistive listening deviceI require material in the following alternative format: Braille, large print, audio, electronic format, another alternative formatI require access to a restroomI require a place to sit if standing for long periods is requiredI require accommodations not listed above
Is there anything else you would like us to know about the accommodations youare requesting?
Please review the following:

Pfizer EUA Fact Sheet - http://labeling.pfizer.com/ShowLabeling.aspx?id=14472

Moderna EUA Fact Sheet - https://www.fda.gov/media/144638/download

Johnson & Johnson Fact Sheet - https://www.fda.gov/media/146305/download

V-Safe Registration - Get vaccinated. Get your smartphone. Get started with v-safe. (cdc.gov)
Please make sure you review the applicable "EUA Fact Sheet" and "V-Safe Registration" above.*

I attest that I have downloaded and reviewed "Pfizer, Moderna or J&J EUA Fact Sheet" and "V-Safe Registration" above.
Please agree to the following*

I certify that, to the best of my knowledge, the information submitted in this application is true and accurate. I understand that the information I provide here will be used to determine my eligibility for receiving the COVID-19 vaccination and when the vaccine will be made available to me. I give my consent to share my information that I provide here as needed with a licensed healthcare provider administering the vaccine, the California Department of Public Health and its contractors, and local health jurisdictions to provide me with COVID-19 vaccination services.
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Hope Pharmacy COVID-19 Vaccine Form