COVID-19 Vaccine Consent Form
mNEXSPIKE
Are you or the patient who is receiving the vaccine 19 years and older?
*
Yes
No
Would you like to schedule an in-home vaccine?
Yes
No
Select an appointment time for the COVID-19 Vaccine. Walk-In's Welcome!
Vaccine Recipient Name
*
First Name
Middle Name
Last Name
Vaccine Recipient Physical Address
*
Street Address
Apt #
City
State Initials
Zip Code
Patient Date of Birth
*
/
Month
/
Day
Year
Gender at birth
*
Please Select
Male
Female
Race
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Ethnicity
*
Please Select
Hispanic or Latino
Not Hispanic or Latino
Unknown
Vaccine Recipient Phone Number
*
Mother's Maiden Name
Required for proper vaccine documentation
Primary Care Provider Name
Emergency Contact Name
Relationship to Emergency Contact
Please Select
Brother
Sister
Sibling
Mother
Parent
Father
Guardian
Spouse
Grandparent
Child
Foster child
Stepchild
Care Giver
Other
Phone Number of Emergency Contact
*
Email
*
example@example.com
COVID-19 Vaccine Screen Questions
*
Rows
Yes
No
1. Are you feeling sick today?
2. In the last 10 days, have you had a COVID-19 Test because you had symptoms and are still awaiting your test results or been told by a healthcare provider or health department to isolate or quarantine at home due to COVID-19 infection, exposure, or travel?
3. Have you been treated with antibody therapy or convalescent plasma for COVID-19 in the past 90 days (3 months)?
4. 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
5.
Have you received any vaccine in the last 14 days
?
6. Are you pregnant or considering becoming pregnant or breastfeeding?
7. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
8. Do you take any medications that affect your immune system, such as cortisone, prednisone, or other steroids, anticancer drugs, or have you had any radiation treatments?
9. Do you have a bleeding disorder or are you taking a blood thinner?
10. Have you had a previous dose of the COVID-19 Vaccine from Super Health Pharmacy? .
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)
*
Rows
Check each box
Overview
I understand
the benefits and risks of the COVID-19 vaccine as described in the Vaccine Information Sheet, a copy of which I was provided.
Consent
I have read,
or had explained to me, the information sheet about the COVID-19 vaccination.
I request
that the COVID-19 vaccination be given to me (or the person named above for whom I am authorized to make this request and provide
surrogate consent). I authorize release of all information needed (including but not limited to medical records, copies of claims and itemized bills) to verify payment and as needed for other public health purposes, including reporting to applicable vaccine registries.
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 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
understand that any monies or benefits for administering the
vaccine will be assigned and transferred to the vaccinating provider (Super Health Pharmacy), including benefits/monies from my health plan, Medicare or other third
parties who are financially responsible for my medical care. I authorize Super Health Pharmacy LLC to bill my insurance. If not covered, I will be responsible to pay out of pocket.
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
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of
Please Upload Supporting Uninsured Document
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Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):
*
Date Signed
/
Month
/
Day
Year
Date
Pharmacist Name
First and Last Name
Pharmacist Signature
Immunizer Name
First and Last Name
Immunizer Signature
Lot Number
Expiration Date:
Pharmacy Name
Submit
Pharmacy NPI
*
Should be Empty: