COVID-19 Vaccine Appointment Scheduling and Consent Form

COVID-19 Vaccine Consent Form

In order to receive the vaccine, you must be in the most appropriate phase of the vaccine rollout. Visit this link (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations.html) for more information at the federal level. States may have a different approach.
Is this a first shot, second shot or a THIRD SHOT Known as BOOSTER SHOT! Please select the correct one.
Please select the category that you fall under and self attest on Booster Shot -

Immunocompromised - Currently, CDC is recommending that moderately to severely immunocompromised people receive an additional dose.Individuals 65 and aboveindividuals 18 through 64 years of age at high risk of severe COVID-19; andindividuals 18 through 64 years of age whose frequent institutional or occupational exposure to SARS-CoV-2 puts them at high risk of serious complications of COVID-19 including severe COVID-19.
Please select an appointment*
Vaccine Recipient Name*

FirstNameMiddle NameLastName
Email*
example@example.com
Vaccine Recipient Physical Address*

Street Address

CityState Initials

Zip Code
Date of Birth*

MonthDayYear
Gender at birth*
Race*
Ethnicity*
Vaccine Recipient Phone Number*

Area CodePhone 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*

Area CodePhone Number

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 30 days? (wait 14 days before getting COVID vaccine)
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? (wait 30 days after)
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?

ONLY answer if you ALREADY received your first dose. COVID-19 vaccine manufacturer for the first dose you PREVIOUSLY received:
Required if you selected "Yes" to #2
Date of first dose (do not complete if you selected "no" to #2 above.)

MonthDayYear
Required if you selected "Yes" to #2
Date of second dose (do not complete if you selected "no" to #2 above.)

MonthDayYear
Required if you selected "Yes" to #2

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 Pfizer/Moderna/J&J 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, some COVID-19 vaccine requires 2 doses given 21-28 days apart depending on the manufacturer. If this is my second 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.
I understand that I will be receiving the vaccination at no cost to me.
On Behalf of myself, my heirs and personal representatives, I hereby release and hold harmless Hague Pharmacy at CHKD, and their staff, associates, successors, 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 hereby acknowledge that the area where vaccination is administered maybe used to photograph and record video and film footage in connection with the promotional and publicity campaign of this and future vaccination site. By your presence in any of our vaccination facility, you acknowledge that you have read this and have been informed that you may be photographed and recorded as part of the release in video, photography and/or any media now known or hereafter devised, in perpetuity throughout the universe and publicity thereof. If you do not wish to be photographed or recorded please let us know immediately if you see any staff, media, or news channel recording you.

TO READ MORE ABOUT THE VACCINE PLEASE CLICK ON THE VACCINE NAME BELOW -

PFIZER EUA

JOHNSON & JOHNSON

MODERNA EUA

The vaccine is available to anyone no matter if insured or uninsured. Please check only one of the following.*

	Check one
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.

What insurance do you have? If no insurance please select uninsured. *
For uninsured patients, please select at least one of the following that you will bring with you to your appointment.

Social Security NumberState identification number and state of issuanceDriver's license number and state of issuance
Please take a Picture of your Driver License, Medicare Red White & Blue Card, and Insurance Card and Upload *

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VACCINE CLINIC LOCATION FOR SUNDAY 09/26/2021 *

	Please acknowledge
BRECKENRIDGE CLUBHOUSE 101 REDWOOD PARK DRIVE, MORRISVILLE, NC 27560

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

Clear
Date Signed

MonthDayYear
Date
Should be Empty:

COVID-19 Vaccine Consent Form