New 08/27/2021 COVID-19 Vaccine Screening Form

COVID-19 Vaccine Consent Form

In order to receive the vaccine, please answer all questions to the best of your knowledge. Please ready Covid Vaccine EUA document available at www.cdc.gov for detailed information, side effects etc on this vaccine. Florida state specific information is found at www.floridahealthcovid19.gov
Vaccination Location

Apex Care Pharmacy 1
Do you qualify to receive the COVID-19 Vaccine as per State Mandate and Guidance for vaccination? *

Yes No (call us before filling this form)
Select an appointment time *
Vaccine Recipient Name *

First Name Middle Name Last Name
Vaccine Recipient Physical Address *

Street Address

Apt #

City State Initials

Zip Code
Date of Birth *

Month Day Year
Gender at birth *
Race *
Ethnicity *
Vaccine Recipient Phone Number *
Mother's Maiden Name
Required for proper vaccine documentation
Primary Care Provider Name
Emergency Contact Name *
Relationship to Emergency Contact *
Phone Number of Emergency Contact *
Email
example@example.com

COVID-19 Vaccine Screen Questions *

	Yes	No
1. Do you have today, or have you at any time in past 10 days a fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion, runny nose, nausea, vomiting or diarrhea?
2. Have you tested positive or have been diagnosed with COVID-19 in past 10 days?
3. Have you had severe allergic reaction (needed epipen or hospital care) to a previous dose of this vaccine or to any ingredients of this vaccine?
4. Have you had any other vaccinations in past 14 days ?
5. Have you had Covid-19 antibody therapy within the last 90 days? (e.g. Convalescent plasma)
6. Do you carry epi-pen or emergency treatment of anaphylexis and/or have allergic reactions to any medication, food, latex etc? ?
7. For women, Are you pregnant or is there a chance you could become pregnant?
8. For women, Are you currently breastfeeding?
9. Are you immunocompromised or on a medication that may affect immune system?
10. Do you have a bleeding disorder or are you on blood thinner/blood thinning medications?
11. Did you receive previous dose of Covid-19 vaccine? If yes, please tell immunizer which manufacturer that was.
12. Are you a current customer of Apex Care Pharmacy 1?

Which arm would you like to get the injection on *

Left Arm Right Arm

Consent (check each box below after reading and prior to signing the form) *

	Check each box
I certify that I am: (a) the patient and at least 16 years of age; (b) the legal guardian of the patient and confirm that the patient is at least 16 years of age; or (c) legally authorized to consent for vaccination for the patient named above. Further, I hereby give my consent to the Florida Department of Health (DOH) or its agents to administer the COVID-19 vaccine.
I understand that this product has not been approved or licensed by FDA, but has been authorized for emergency use by FDA, under an EUA to prevent Coronavirus Disease 2019 (COVID-19) for use in individuals either 16 years of age or older or 18 years of age and older; and the emergency use of this product is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of the medical product under Section 564(b)(1) of the FD&C Act unless the declaration is terminated or authorization revoked sooner.
I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccine(s). I understand the risks and benefits associated with the above vaccine and have received, read and/or had explained to me the Emergency Use Authorization Fact Sheet on the COVID-19 vaccine I have elected to receive. I also acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction.
I acknowledge that I have been advised to remain near the vaccination location for approximately 15 minutes (or more in specific cases) after administration for observation. If I experience a severe reaction, I will call 9-1-1 or go to the nearest hospital. .
On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless the State of Florida, the Florida Department of Health (DOH), the Florida Division of Emergency Management (FDEM) and their staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the vaccine listed above.
I acknowledge that: (a) I understand the purposes/benefits of Florida SHOTS, Florida’s immunization registry and (b) DOH will include my personal immunization information in Florida SHOTS and my personal immunization information will be shared with the Centers for Disease Control (CDC) or other federal agencies.
I further authorize DOH, FDEM, or its agents to submit a claim to my insurance provider or Medicare Part B without supplemental coverage payment for me for the above requested items and services. I assign and request payment of authorized benefits be made on my behalf to DOH, FDEM, or its agents with respect to the above requested items and services. I understand that any payment for which I am financially responsible is due at the time of service or if DOH invoices me after the time of service, upon receipt of such invoice.
I acknowledge receipt of the DOH Notice of Privacy Practices.

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

Cancel of
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

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

Clear
Date Signed

Month Day Year
Date
Pharmacist Name
First and Last Name
Pharmacist Signature

Clear
Immunizer Name
First and Last Name
Immunizer Signature

Clear
Lot Number
Expiration Date:
Vaccine Manufacturer

J & J
Pharmacy Name
Pharmacy NPI *
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform

COVID-19 Vaccine Consent Form

Vaccination Location