Young Pharmacy - Covid-19 Vaccine Consent Form
We are located at 23 WOODMERE MALL in CROSSVILLE, TN and are in the Central Time Zone. To CANCEL or RESCHEDULE an appointment please call us at 931-456-8165 weekdays between 8am and 6pm.
Moderna SpikeVax 2023-2024: approved for everyone age 12+
Bivalent booster should be given at least TWO MONTHS after your last booster/dose.
Pharmacy Notes:
Which vaccine are you making an appointment for?
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1st Dose of Moderna
2nd Dose of Moderna (must be 28 days after 1st dose)
Bivalent Booster of Moderna (ages 18+ and has been two months since any previous doses)
Vaccine
Select an appointment DATE and TIME. *** Bivalent boosters must be 2 months after previous doses
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Appt Date
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Month
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Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
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Patient's Name
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First Name
Middle Name
Last Name
Patient's Phone Number
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A number where the patient or contact person can be easily reached.
Date of Birth
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Month
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Day
Year
Would you like to fill out the remaining vaccine consent information or wait until you are at your appointment?
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Fill it out now
Wait for my appointment
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Young Pharmacy COVID-19 Vaccine Consent Form
Vaccines are being given in our middle and outer drive-thru lanes. Please stay in your vehicle when you pull-in, and we will come out to you.
Patient's Physical Address
Street Address
Street Address Line 2
City
State Initials
Postal / Zip Code
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
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
COVID-19 Vaccine Screening Questions
Yes
No
Don't Know
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 a
component 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 14 days?
7. Have you ever had a positive test for COVID-19 or has a health care provider told you that you had COVID-19?
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?
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 Moderna Fact Sheet is available at the end of this form), 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, the Moderna COVID-19 vaccine requires 2 doses given at least 28 days apart. 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.
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.
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
A copy of the Vaccine Information Statement.
You can sign up for V-Safe and report how you feel afterwards.
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
Our Privacy Policy
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I understand that if I did not fill out the vaccine consent form, or did not fill in all the required information, I will be asked to complete it when I arrive for my appointment.
*
Yes
No
Email address for submission confirmation
example@example.com
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Submit Consent Form (REQUIRED)
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Please reset the form and choose "Booster dose."
A 3rd dose is ONLY recommended if you are severely immunocompromised. If you think you need a 3rd dose but answered "none", contact the pharmacy during normal business hours at 931-456-8165 for assistance.
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