Immunization Screening and Consent Form

Immunization Screening and Consent Form
Name (Last) *
(First) *
Date of Birth *

Month Day Year
Date
Age *
Address *
City *
State *
Zip *
Phone Number *
Gender at Birth *
Race
Ethnicity *
Emergency Contact Name *
Relationship *
Emergency Contact Phone Number *
Primary Care Physician Name *
PATIENT QUESTIONS - ANSWER THE DAY OF VACCINATION
Which Vaccine(s) are you receiving today? *

Covid 19: Pfizer Covid-19: Moderna Flu for 65 years + Flu for 6-64 years old Pneumonia Tdap Hep A Hep B MMR Meningococcal ACWY Shingles Other
Have you ever received a dose of COVID-19 Vaccine? *

No Yes Not applicable, I am not receiving a Coivd-19 Vaccine today
Date of Last Dose

Month Day Year
Date
Are you feeling sick today?

No Yes

Have you ever had an allergic reaction or serious reaction to: (This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen or that caused you to go to the hospital. It would also including an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing)

	No	Yes
A component of the COVID-19 Vaccine or any vaccine, including Polyethylene Glycol (PEG), which is found in some medications such as laxatives and preparations for colonoscopy procedures.
Polysorbate
Eggs, Thimerosal or Latex
A previous dose of Covid-19 Vaccine, any other vaccine or injectable medication

Have you ever had a positive test for COVID-19 or a healthcare provider told you that you had COVID-19?

No Yes
What date did you test positive for COVID-19?

Month Day Year
Date
Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment forCOVID-19? [Note: monoclonal antibodies does not include antibiotics that would be prescribed to you and filled at a pharmacy.]

No Yes
Have you received a vaccine in the last 4 weeks?

No Yes
Which vaccine have you received in the last 4 weeks?
Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressant drugs or therapies?

No Yes
Have you ever had a seizure disorder requiring seizure medication(s), a brain disorder or Guillain-Barre Syndrome (condidtion that causes paralysis)?

No Yes
Do you have a bleeding disorder or are you taking blood thinner?

No Yes
Are you pregnant or breastfeeding?

No Yes
What type of insurance do you have? *

Medicare Commercial Medicaid / Kancare Uninsured
If you are on Medicare, please provide the following:
Medicare Beneficiary ID blanks
Social Security Number blank
If you are uninsured and receiving a Covid-19 Vaccine please provide one of the following:
Social Security Number blanks
Driver's License Number
Which Kancare Plan are you currently enrolled in?
For children under the age of 18 and on Kancare, we will not be able to vaccinate with any vaccine except COVID-19 vaccine because pharmacies are not allowed to participate in the Vaccine For Children Program.
If you are on a commercial insurance plan, please provide us with a picture of the front and back of your insurance card or bring your insurance card with you to your appointment.
Please help us bill your insurance for your vaccine by taking a picture of the front and back of your Medicare Card, Medicare Advantage Card, Commerical Insurance Card or Kancare Card. Alternatively, you can bring your card to your appointment.
Front of Card
Back of Card
For Covid-19 Vaccine:

I request the vaccine to be given to me or to the person named above, a minor for whom I represent and I am authorized to sign this consent form. I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet, a copy of which I was provided with this consent form (online or in print). I have had a chance to ask questions that were answered to my satisfaction. 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. I understand that I will be receiving the vaccination at no cost to me. If insured, I authorize the pharmacy to bill my insurance on my behalf for the the immunization – understanding that I will not incur any costs. If uninsured, I attest that I do not have any insurance, including, but not limited to Medicare, Medicaid, or any other private or government-funded benefit plan. If uninsured, I authorize the pharmacy to use my social security number or driver’s license number to bill the United States Health Resources & Services Administration’s COVID-19 Program, understanding that I will not incur any costs. I understand that at this time, some COVID-19 vaccines require 2 doses given 21-28 days apart dependent on the manufacturer. If this is my first dose of the COVID-19 vaccine and a second dose is required (Pfizer and Moderna only), I intend to receive a second dose of the same vaccine in accordance with the timeframe specified in the Fact Sheet to complete the series.

For all other Vaccines:

By signing this form, I agree to be vaccinated today by El Dorado TrueCare Pharmacy. I have received and understand information about the vaccines designated above. I have had my questions answered to my satisfaction. I oauthorize the payment of medical benefits to the provider performing the service. If I have a copayment or the vaccine is not covered on my insurance, I will remit payment to El Dorado TrueCare Pharmacy.
Date of Consent *

Month Day Year
Date
Signature

Clear
Covid-19 Dose in Series
Route of Administration of Covid-19 Vaccine

IM-L Arm IM-R Arm
Covid-19 Date of Administration

Month Day Year
Date
Covid-19 Vaccine Manufacturer
Covid-19 Lot Number
Covid-19 Expiration Date
Covid-19 Vaccinator Name
Vaccine 2
Route of Administration Vaccine 2

IM- L Arm IM- R Arm
Vaccine 2 Date of Vaccination

Month Day Year
Date
Vaccine 2 Lot Number
Vaccine 2 Expiration Date
Vaccinator Name
Vaccine 3
Route of Administration Vaccine 3

IM-L Arm IM-R Arm
Vaccine 3 Date of Administration

Month Day Year
Date
Vaccine 3 Lot Number
Vaccine 3 Expiration Date
Vaccine 3 Vaccinator Name
Which Dose do you wish to receive today

First Dose Second Dose Booster Dose
Should be Empty:

Immunization Screening and Consent Form

PATIENT QUESTIONS - ANSWER THE DAY OF VACCINATION