COVID Permission English

COVID-19 Vaccination Consent to Treat Unaccompanied Minor Form

Walmart requires the consent of a parent or legal guardian to provide COVID-19 vaccines to a minor child. Pharmacists/technicians shall ensure that the minor meets the minimum state age limit required for the applicable vaccine and maintains appropriate consent documentation.

Patient Name*

Date of Birth*

Date

Parent or Guardian Name*

Relationship to Patient*

Date*

Date

Consent to Treat Unaccompanied Minor form

My minor child, who is less than 18 years of age may present without me to receive a COVID-19 vaccine from Walmart/Sam's Club pharmacies. My minor child is authorized by me to receive a COVID-19 vaccine. This consent is in effect until my minor child completes all recommended vaccine doses, but no longer than 90 days from the date listed above.

Parent or Legal Guardian Name*

Parent or Legal Guardian Signature*

In case of an Emergency, I can be reached at

Home

Work

Cell*

Please send current insurance information with your minor child.

Walmart and Sam's Club Vaccine Administration Record and Informed Consent

Manual Reporting Initials (For Pharmacist Use Only)

Date (For Pharmacist Use Only)

Date

Time (For Pharmacist Use Only)

Pharmacist Verification (For Pharmacist Use Only)

Patient NamePatient DOB

Gender*

FemaleMale

Date of Birth*

Date

Address*

Home Address

Street Address Line 2

CityState

Zip

Phone Number*

Race*

Ethnicity*

Hispanic/LatinoDecline to StateNot Hispanic or Latino

Do you have a Primary Care Physician?*

YESNO

Primary Care Physician Name

Street Name

Do you authorize this pharmacy to send your information to your Primary Care Physician?

YESNO

Vaccine Requested*

FluCOVID-19

Section B Questions (1-7) below pertain to all vaccines and will help us determine your eligibility to be vaccinated today.*

	Yes	No
Is the person to be vaccinated sick or injured today?
If Yes, Does the person have a new or moderate to high fever?
If Yes, Does the person have a cough?
If Yes, Does the person have diarrhea?
If Yes, Has the person been vomiting?

Pharmacist initials after reviewing with patient (For Pharmacist Use Only)

Please answer the following questions.*

	Yes	No
Does the person to be vaccinated have allergies to medications, food components, vaccine components, or latex?Examples: eggs, bovine protein, gelatin, gentamicin, polymyxin, neomycin, phenol, yeast, thimerosal
Does the person to be vaccinated have a chronic health condition or long-term health problem? Examples: heart, lung, kidney, neuromuscular, liver, metabolic diseases, asthma, diabetes, anemia, other blood disorders, neurologic or is the patient a smoker?
Has the person to be vaccinated ever had a reaction, fainted, or felt dizzy after receiving a vaccine or has any physician or other healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a medical setting?
Has the person to be vaccinated ever had a seizure disorder for which they are on seizure medications, a brain disorder, Guillain-Barre Syndrome, or other nervous system problems?
Is the person to be vaccinated currently pregnant, considering becoming pregnant in the next month, or breast-feeding?
Does the person to be vaccinated have a weakened immune system, is in contact with anyone with a severely weakened immune system or in long-term treatment with drugs such as high-dose steroids? Examples: cancer, leukemia, lymphoma, HIV/AIDS, transplant, rheumatoid arthritis, ankylosing spondylitis, Crohn's disease or any other immune system disorder?

For persons in North Carolina, OR if the person will be receiving COVID-19, varicella, measles/mumps/rubella (MMR II), shingles, answer the following questions.

	Yes	No
Has the person to be vaccinated received any vaccinations or skin tests in the past four weeks?
Is the person to be vaccinated currently on home infusions, weekly injections (such as Remicade, Humira, Enbrel, Cimzia, Simponi, Simponi Aria, Xeljanz, Orencia,Arava, Actermra, Cytoxan, Rituxan, adalimumab, infliximab or etanercept), high dose methotrexate, azathioprine, mercaptopurine, anticancer drugs, antivirals or radiation treatment, cortisone or high-dose steroid therapy (prednisone >20mg/day or equivalent) for longer than two weeks?
Has the person to be vaccinated received antibodies, a transfusion of blood or blood products, been given immune (gamma) globulin, or antivirals in the past year?
Does the person to be vaccinated have a history of thrombocytopenia or thrombocytopenia purpura (MMR II only)?

Please read the section below carefully and sign and date acknowledging that you understand and agree.

I hereby give consent to Walmart, as applicable, to administer the medications(s) I have requested above. I understand the benefits and risks of receiving this medication and have received, read and/or had explained to me the Vaccine Information Statement and/or Vaccine Patient Fact Sheet for the vaccine(s) I have elected to receive. I have had a chance to ask questions and that such questions were answered to my satisfaction. I acknowledge that I have been advised to remain near the vaccination location for approximately 15 minutes after administration for observation by the administering healthcare provider. On behalf of myself, my heirs, and personal representatives, I fully release and discharge Walmart, its staff, agents, successor, division, affiliates, officers, directors, contractors, and employees fromanyand all liabilities or claims whether known or unknown arising in any way related to the administration of the vaccine(s) listed above. Initials:*

I understand, acknowledge, and consent that the administration of this vaccine will be entered into my state's immunization registry. I understand the purposes/benefits of my state's immunization registry and acknowledge that, depending upon my state law, I may prevent disclosure of my immunization to the state registry with a signed Opt-Out. The Pharmacist has informed me that I may have the right to refuse. I acknowledge that the administration of this vaccine will be reported to any required local, state, or federal health authorities. Initials:*

I assign payment of authorized insurance benefits due to me to be paid to the pharmacy. I consent to the release of medical information when necessary for billing, reimbursement, and medical protocol. Initials:*

I am aware a pharmacist, qualified pharmacy technician or state authorized pharmacy intern, as allowed by law, might be administering this medication. Initials:*

By initialing here, I acknowledge receipt of Walmart/Sam's Club Health & Wellness Notices. I understand that the Notice is subject to change, and I can obtain a current Notice online at www.walmart.com, www.samsclub.com, or at any local store or club location. Refusing to initial and acknowledge receipt will have no impact on my treatment. Initials:*

Patient/Legal Guardian Name*

Signature*

Date*

Date

The following section is to be completed by a health care provider ONLY.

Pharmacist Name (Print)

Pharmacist Signature

Administering Individual Name and Title (Print)

Administration Date/Date VIS Given

Date

	Vaccine	Lot #	Exp. Date	Manufacturer	NDC	Dosage	Site	Route	VIS Date	RPh Initials
1
2

Date*

Date

Patient Name (First & Last)*

Phone Number*

Section A: Insurance Coverage Information

Please provide all applicable insurance information below. FOR COVID-19 IMMUNIZATIONS ONLY: If you have no active insurance coverage, skip section A and complete section B below.

Note: For active insurance coverage, but unsure of your insurance information, provide the last 4 digits of your Social Security Number.

OPTION 1: Pharmacy Insurance Information:

Insurance Carrier

Patient ID

Primary Cardholder (Y/N)

Dependent Number

BIN

PCN

Group

OPTION 2: Medical Insurance Information:

Insurance Carrier

Patient ID

Group

Payer ID

Medicare Insurance Information (RED, WHITE & BLUE CARD)

Name (as it appears on the card)

Medicare ID #

Section B: No Insurance Coverage Attestation

Complete the section ONLY if you are receiving a COVID-19 immunization AND do not have active insurance coverage.

The Federal government wants to make sure that all individuals can receive the COVID-19 Vaccine regardless of health insurance status. Walmart is participating in the federal government's COVID-19 Uninsured Program. If you do not have insurance, we are asking you to confirm this fact to ensure we correctly file the claim for your vaccination service. We will need one of the below forms of identification.

Driver's License Number

State Issued ID

I hereby declare that I do not have insurance coverage of any kind including, but not limited to Commercial Insurance, Medicare, or Medicaid. I understand that my lack of insurance does not prevent me from receiving the COVID-19 Vaccine. I understand that I will not be charged for the vaccine administration. I agree to inform my pharmacists if I am enrolled in Medicaid within the next 30 days.

Patient Signature

Section C: Long Term Care Facility (LTCF) Clinic - Place of Service Confirmation

Complete the section ONLY if you are receiving an immunization at a LTCF.

Place a check next to the administration setting below in which you are receiving your vaccination to ensure we correctly file the claim for your vaccination service.

Communal Setting at the Long Term Care Facility (no reason or signature required)Patient Room (reason and signature required below)

I confirm that the vaccination service was provided in my patient room as indicated below.

Reason

Patient Signature

Insurance Attestation Form