Vaccine Sign up & Consent Form (all but Covid-19)

Family Pharmacy Vaccine(s) Signup Form
Age
Today's Date*

MonthDayYear
Patient Name *

First NameLast Name
Email*
example@example.com
Date of Birth

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender*

FemaleMalePrefer not to answerOther
Race*

African AmericanNative AmericanAsianWhiteNative Hawaiian/ Other Pacific IslanderPrefer not to answerOther
Ethnicity:*

Hispanic or LatinoNon-Hispanic/LatinoUnknownPrefer not to answerOther
Primary Doctor Name

First NameLast Name
I would like to get the following vaccine(s)-check all that apply:

Prevnar 20 (Pneumonia-single dose)Shingrix (shingles)-1st Dose (50 yrs and older)Shingrix (shingles)-2nd Dose given 2-6 Months after initial doseTdap (Adacel)RSV Vaccine (Abrysvo) for 75 yrs and older)(60 to 74 yrs old may be eligible with certain medical conditions. Call to see if your eligible) -[PLEASE don't schedule for same day appointment]( ONLY 2 LEFT !! ) Influenza Vaccine (Ages 3-64)(ONLY 6 LEFT !!! ) High Dose Flu Vaccine (Over 65 yrs old)
I would like to get the following vaccine:

( OUT OF STOCK !!! )Covid-19 Vaccine (Spikevax) 2025-2026
I would like to get the updated 2025-2026 Covid-19 Vaccine by Moderna (Spikevax). Please select any one of the following if it applies to you. All choices after the 1st pertain to ages (12-64). In Maryland everyone who wants the Covid-19 Vaccines is eligible. By registering for the Covid-19 Vaccine, you are attesting that you have had the opportunity to ask questions that were answered to your satisfaction. (I understand the benefits and risks of the vaccine and consent to the vaccine administration.)*

I'm 65 Years old or olderCancerCerebrovascular disease (stroke)Cystic FibrosisDementia or Neurological conditions (including Parkinson's Disease)Disabilities (developmental, intellectual, birth defects, cerebral palsy, spinal cord injuries, Down Syndrome, ADHD)Heart Condition (heart failure, CAD cardiomyopathies)Blood Disorders (sickle cell, thalassemia)HIV InfectionImmunocompromised states (cancer treatment, organ transplant, corticosteroids, primary immunodeficienciesMental health conditions (depression, schizophrenia)Overweight & Obesity (BMI >25, risk rises with BMI)Physical InactivityPregnancy and Post-partum (within 42 days)Smoking (current or former)Organ or stem cell transplantSubstance use disorders (alcohol, opioids, cocaine)Tuberculosis (TB)
Insurance Information*

CommercialMedicareUninsured
Insurance Company Name
Commercial Insurance Info

Member ID NumberGroup NumberRX Bin NumberPCN
Medicare Information

Medicare NumberPart A DatePart B Date
Please Upload Copy of your Insurance Card Here:

Cancelof
Insured Patients

I authorize the pharmacy to bill my insurance on my behalf for the immunization.
Uninsured Patients

I do not have any insurance, including but not limited to Medicare, Medicaid or any other private or government-funded health benefit plan. I understand I will pay for the selected vaccine prior to getting vaccinated in the pharmacy.
- Does the person to be vaccinated have a fever or illness today?*
  
  YesNo
- Does the person to be vaccinated have an allergy to eggs, latex, or to a component of the vaccine?*
  
  YesNo
- Has the person to be vaccinated ever had a serious reaction to this vaccine in the past?*
  
  YesNo
- Has the person to be vaccinated ever had Guillain-Barre syndrome less than 6 weeks after vaccination, uncontrolled seizures or any unstable neurological disorder?*
  
  YesNo
- Has the person to be vaccinated received any vaccines in the past 30 days?*
  
  YesNo
- Is the person to be vaccinated currently pregnant, breastfeeding, or planning to become pregnant in the next 30 days?*
  
  YesNo
- I, undersigned, agree with the following:*
  
  I certify that the information above is correct and accurate to the best of my knowledge.I have been given a copy via email and can have explained, the information in the "Vaccine Information Statement" regarding the vaccine I am receiving.All my questions concerning the vaccine have been answered to my satisfaction.I understand the benefits and risks of receiving the vaccine and request that it be given to me.I understand my pharmacy may submit this immunization information to the state immunization registry or appropriate healthcare provider.
- Date*
  
  MonthDayYear
  Date
- Signature*
- I would like to have the following arm injected*
  
  LeftRight
- ** PLEASE WEAR A GARMENT THAT ALLOWS EASY ACCESS TO UPPER ARM AREA TO EASE VACCINE ADMINISTRATION. **
- I am interested in switching to Family Pharmacy as my preferred pharmacy for my prescription needs.*
  
  Yes! Please call me to discuss further.Yes! Please call my existing pharmacy to transfer my prescriptions.Yes, Please call my doctor to have my prescriptions sent to Family Pharmacy.I'm already a happy Family Pharmacy patient!No thank you ☹️
- Pharmacy Name* Existing Pharmacy Name Phone Number* Pharmacy Phone Number
- Appointment*
- _________________________________________________________________________________________
  
  Pharmacy Staff Only:
  
  Vaccine Administered by (circle one): Tony Brocato RPh, Eric Yospa RPh, Wayne Yelle PharmD, Shannon Burick, CPhT, Ryann Yospa, CPhT
  
  Signature____________________________________________________
- Should be Empty:

Family Pharmacy Vaccine(s) Signup Form