COVID Vaccine Consent Form

18 years of age and older are elegible to receive this vaccine.
Every patient will be requested an ID before vaccination.
If you have any questions, please call us at (305) 665 4411

IMPORTANT:
Inmunocompromise patients are recommended a full 3rd dose 28th days after the 2nd dose

Booster shot for elegible patients, is equivalent to half the dose from the primary series

What dose of the COVID-19 vaccine will this be? *

First Dose Second Dose Third Dose (full dose for immunocompromised patients only) Booster shot (half the dose, ages 18 years and older)

For more information about the CDC recommendations for immunocompromised patients, please visit:

https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/immuno.html

Please provide the date of your last dose: *

3rd dose is recommended 28 days after the 2nd dose for immunocompromised patients

Please provide the date of your last dose : *

Booster shot is recommended 5 months after the 2nd dose for elegible patients

Vaccine Appointment:

*

2nd Dose Vaccine appointment: Please select a time of your convenience, the first date available corresponds to 28 days after your first shot as per CDC recommendations. *

Personal Information:

Email *

example@example.com

Patient's Full Name: *

Last Name First Name

Date of Birth: *

Gender *

F: Female / M: Male / U: Unknown

Address: *

Street address

Street Address Line 2

City State

FL County of Residence *

Phone Number: *

Ethnicity *

Y: Hispanic or Haitian origen / N: Not hispanic or Haitian origen / U: Unknown

Date of vaccination

Date

Vaccine provided

Vaccine manufacturer

Vaccine Lot Number

058H21A

Vaccine NDC

MOD

Vaccine expiration date

03/26/2022

Injection Site

LD: Left Deltoid / RD: Right Deltoid

Injection Route

IM: Intramuscular

Eligibility

Risk Factors

Vaccine given by

Given by credentials

Tittle

Immunization Screaning Questionnaire:

Please select the correct option below: *

	Yes	No
COVID-19 Screening Questions: In the past two weeks, have you tested positive for COVID-19 or are you currently being monitored for COVID-19?
In the past two weeks, have you had a known exposure with anyone who tested positive for COVID-19?
Have you had a new onset of fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, nausea, vomiting, or diarrhea?
Questionnaire for Immunization: Do you feel sick today?
Do you have an allergy to medications, foods, or any vaccines (eggs, gelatin, thimerosal, neomycin, gentamicin, latex, aluminum, preservatives, baker's yeast, etc.)?
Do you carry an EpiPen?
Have you been diagnosed with or suspected of having covid in the last 90 days?
If yes to the above question, did you receive medications, plasma or other treatment?
Have you ever had a serious reaction or fainted after receiving any vaccination?
Have you ever had a seizure, brain disorder, or Guillain-Barre Syndrome?
Have you received any other immunizations in the last 14 days?
Are you immunocompromised or on a medication that affects the immune system
Are you currently breastfeeding
Are you pregnant or are you planning on becoming pregnant during the next month?
Do you have any bleeding disorder or are you on a blood thinner/blood-thinning medication?

Please specify allergens: *

Type none or N/A if any

Are you allergic to polyethylene glycol (PEG): *

Yes No I'm not sure

Are you allergic to polysorbate: *

Yes No I'm not sure

Insurance Information:

*

I authorize the pharmacy to bill my insurance on my behalf for the immunization and the information provided is true and accurate. I do not have any insurance, including but not limited to Medicare, Medicaid or any other private or government-funded health benefit plan

Please upload a picture of your insurance card and/or MEDICARE card (front and back) : *

Browse Files

In order to have your vaccine administration fee paid for by the United States Health Resources & Services Administration's COVID-19 Program for uninsured patients, please select to provide one of the following: (skip if you don't have the info available)

Social Security Number State identification number and state of issuance Driver's license number and state of issuance

Number of the document selected above

Signatures:

I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA), a copy of which I will be provided as an attachment with this Consent and Release. 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 and Release.

HIPAA DISCLOSURE

AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION

I hereby voluntarily authorize the disclosure of my protected health information, including any vaccination records, provided by Marco Drugs & Compounding pharmacy to:

Me via email, even though email is not a completely secure means of communication.
Me via SMS, even though SMS is not a completely secure means of communication.
The Florida Health Department and the Center for Disease Control and Prevention.

I also understand and agree to the following:

I may refuse to provide this authorization.
I may revoke this authorization at any time in writing.
I have a right to request and receive a copy of this authorization.
This authorization is effective immediately upon signing this form.

Signature: *

Clear

By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge.

YOU ARE CURRENTLY NOT ELEGIBLE TO GET A 3RD DOSE OF THE MODERNA COVID VACCINE

3rd dose is recommended 28 days after
the 2nd dose for immunocompromised patients

YOU ARE CURRENTLY NOT ELEGIBLE TO GET A BOOSTER OF THE MODERNA COVID VACCINE

Booster shot is recommended 5 months after
the 2nd dose for elegible patients

COVID-19 MODERNA VACCINE REGISTRATION AND CONSENT FORM