Pfizer IN- STORE Lititz Apothecary Consent Form

Rules to receive the COVID Vaccine Location:

Location: 100 East Main St Lititz PA 17543

Date/Day: Monday through Saturday

UPDATE 4/18/2023:

- Individuals 65 years of age and older who have received a single dose of a bivalent vaccine may receive one additional dose at least four months following their initial bivalent dose.

- Most individuals who have already received a single dose of the bivalent vaccine are not currently eligible for another dose. The FDA intends to make decisions about future vaccination after receiving recommendations on the fall strain composition at an FDA advisory committee in June.

- Immunocompromise who have received a bivalent COVID-19 vaccine may receive a single additional dose of a bivalent COVID-19 vaccine at least 2 months following a dose of a bivalent COVID-19 vaccine

- Children 6 months through 5 years of age who have received one, two or three doses of a monovalent COVID-19 vaccine may receive a bivalent vaccine, but the number of doses that they receive will depend on the vaccine and their vaccination history

- Most unvaccinated individuals may receive a single dose of a bivalent vaccine, rather than multiple doses of the original monovalent mRNA vaccines.

Once you hit “Submit” you will be prompted to print a form and bring the form with you to your appointment. The form will be emailed to you at the email address you provided and can be printed from your email at a later time, if desired. It is very important that you bring this form with you to the event as it is required for vaccination. If you are unable to print the form, someone will assist you when you arrive at the pharmacy.

- Click here to Download and/or View the Pfizer COVID Vaccine Facts Sheet.

- Please be sure to bring your insurance card with you and if you are on MEDICARE please be sure to bring your red white and blue Medicare card as the advantage plans are not processing this information yet.

- Dress appropriately for the vaccine in order to allow your upper arm to be easily accessed.

What time did you select above for your appointment (this will print on your form)

Hour Minutes

AM/PM Option

Select Appointment Time*

What date did you select above for your appointment (this will print on your form)

Date

Email*

example@example.com

Vaccine Recipient LEGAL Name*

First NameMiddle NameLast Name

Cell Phone Number

Please enter a valid phone number.

Date of Birth*

Gender at Birth*

Vaccine Recipient Physical Address*

Street Address

Street Address Line 2

CityState Initials

Postal / Zip Code

Mother's Maiden Name

Required for proper vaccine documentation

Ethnicity*

Race*

What what the date of your latest dose?

Date

COVID-19 Vaccine Screen Questions*

	Yes	No
1. Are you feeling sick today?
2. Have you ever received a dose of COVID-19 Vaccine?
3a. Have you ever had an allergic reaction to acomponent of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures?
3b. Have you ever had an allergic reaction to Polysorbate?
3c. Have you ever had an allergic reaction to a previous dose of COVID-19 Vaccine?
4. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?
5. 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.
6. Have you received any vaccine in the last 14 days?
7. Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19?
8. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? [note: monoclonal antibodies does not include antibiotics that you would be prescribed and filled at a pharmacy]
9. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
10. Do you have a bleeding disorder or are you taking a blood thinner?
11. Are you pregnant or breastfeeding?

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/Pfizer/JJ 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 understand that at this time, the COVID-19 vaccine requires 3-4 doses depending on the manufacturer. If this is my second, third or fourth dose, I will bring my vaccine card with me to be completed.
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.

Which arm would you like the vaccine in?

LeftRight

Signature of Person to Receive Vaccine & EUA /VIS: (or Signature of Parent/Guardian if Patient is < 18 years old): *

Clear

Date Signed

Date

Lititz Apothecary COVID-19 Vaccine Consent Form