Pfizer/Moderna Bivalent Pediatric Lititz Apothecary Consent Form

Rules to receive the COVID Vaccine Location:

Location: Lititz Apothecary (100 East Main St. Lititz PA 17543)

UPDATED 10/18/2022:

- We are expected to receive the Bivalent Pfizer and Moderna as early as today and will be begin admistering.

Eligibility:

Pfizer: Ages 5-11 years old and for whom it has been at least 2 months since their last COVID-19 vaccine dose.

Moderna: Ages 6-17 years old and for whome it has been at least 2 months since their last COVID-19 vaccine dose.

- Once you hit “Submit” you will be prompted to print a form and bring the form with you to your appointment. The form will be emailed to you at the email address you provided and can be printed from your email later, if desired. It is very important that you bring this form with you to the event as it is required for vaccination.

- There will be a PDF that will be provided on the "Thank You" email please PRINT and provide this to the intake team.

NOTE: We are no longer doing first and 2nd doses of Pedatric Vaccine and will only be administering Booster when available.

- Only one parent per child should be present inside the facility

- Please arrive no earlier than 5 minutes prior to your appointment time. This is to avoid proper workflow and improve efficiency

- Please bring ID of the parent the child is with along with all medical insurance information.

- Dress appropriately for the vaccine in order to allow your upper arm to be easily accessed.

We need your cooperation in order to successfully administer Covid-19 vaccines to as many people as possible. Non-compliance to the above instructions significantly affects our ability to work efficiently.

Select Appointment Time *

What time did you select above for your appointment (this will print on your form)

Hour Minutes

AM/PM Option

Which Bi-Valent Vaccine do you wish to your child to receive?

What date did you select above for your appointment (this will print on your form)

Date

Email *

example@example.com

Gender at Birth *

Vaccine Recipient LEGAL Name *

First Name Middle Name Last Name

Cell Phone Number

Please enter a valid phone number.

Date of Birth *

Vaccine Recipient Physical Address *

Street Address

Street Address Line 2

City State Initials

Postal / Zip Code

Mother's Maiden Name

Required for proper vaccine documentation

Ethnicity *

Race *

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 14 days?
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?
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?

Date of most recent Covid Vaccine dose?

Date

Consent (Signing this consent form you attest to the following):

• The minor patient is 5 years of age or older

• I have the legal authority to consent to the administration of the Moderna/Pfizer-BioNTech COVID-19 Vaccine to the minor patient

• I understand that the U.S. Food and Drug Administration (“FDA”) has authorized the emergency use of the Moderna/Pfizer-BioNTech COVID-19 Vaccine, which is not an FDA-approved vaccine.

• I have been provided access to and read the Pfizer-BioNTech/Moderna COVID-19 Vaccine EUA Fact Sheet for Recipients and Caregivers (“Fact Sheet”). (Read the Fact Sheet at https://www.fda.gov/media/144414/download

• I understand the known and potential risks and benefits of COVID-19 Vaccine and the extent to which such risks and benefits are unknown.

• I understand that I have the option to accept or refuse Pfizer-BioNTech COVID-19 Vaccine on behalf of the minor patient.

• I consent to and authorize all medically necessary treatment in the rare event that the minor patient has a reaction to the vaccine, including but not limited to itching, swelling, fainting, anaphylaxis, and other reactions.

• The minor patient and I agree that the minor patient will remain in the observation area for the required time period following vaccine dose administration.

Please Initial Consent Attestation: *

Clear

Enter Your Bin Number and PCN from Insurance Card as above

RX Bin Number (6 Digits) RX PCN (Enter None, if not present)

Enter Your Number and PCN from Insurance Card as above

Insurance ID RX Group Number

Enter the first and Last name of the parent and/or gaurdian that is bringing patient

First Name Last name

Would you your child to receive the Flu Vaccine at the same appointment? *

Would you like receive no cost AT HOME COVID test kits?

Which arm would you like the vaccine in? *

Left Right

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

Clear

Date Signed

Date

Lititz Apothecary IN-STORE PEDS COVID19 Vaccine Consent Form