Professional Pharmacy Covid-19 Vaccination Form (Pfizer 5-11yo)

Child's Name

First Name Middle Initial (Optional) Last Name Suffix

Thank you for your interest in scheduling a COVID-19 Vaccine at Professional Pharmacy!

We must adhere to the current Maryland vaccine regulations criteria:

All Marylanders 5 years and older

The U.S. Food and Drug Administration (FDA) has issued an Emergency Use
Authorization (EUA) to permit the emergency use of the unapproved product,
Pfizer-BioNTech COVID-19 Vaccine, for active immunization to prevent COVID-19 in individuals 5 years of age and older.

Please DO NOT MAKE AN APPOINTMENT if you don’t fit the current vaccine criteria listed above for the date of your appointment. You will be asked to verify that you are in fact eligible based on the current priority groups and if unable, your appointment will not be honored and we risk wasting a dose of vaccine.

If you are looking to obtain a booster dose of the Pfizer vaccine, please ensure that you qualify, utilizing the following measures:
- People 65 years and older and residents in long-term care settings should receive a booster shot of Pfizer-BioNTech’s COVID-19 vaccine at least 6 months after their Pfizer-BioNTech primary series,
- People aged 50–64 years with underlying medical conditions should receive a booster shot of Pfizer-BioNTech’s COVID-19 vaccine at least 6 months after their Pfizer-BioNTech primary series,
- People aged 18–49 years with underlying medical conditions may receive a booster shot of Pfizer-BioNTech’s COVID-19 vaccine at least 6 months after their Pfizer-BioNTech primary series, based on their individual benefits and risks, and
- People aged 18-64 years who are at increased risk for COVID-19 exposure and transmission because of occupational or institutional setting may receive a booster shot of Pfizer-BioNTech’s COVID-19 vaccine at least 6 months after their Pfizer-BioNTech primary series, based on their individual benefits and risks. Includes healthcare workers, teachers, residents of homeless shelters and prisons.

We also recommend that you make a NOTE of your APPOINTMENT Date and Time and PRINT the PDF of your form once you hit submit. You may do this on the "Thank You" page that appears after your form is submitted successfully. Please bring this and any insurance cards with you for your appointment.

If you are unable to find a vaccine appointment time, please check back regularly or call the store to be placed on our wait list for cancellations. Please note that we will call wait list patients on short notice and you must be able to come to the pharmacy quickly to help us prevent wasted vaccine.

I certify that my child in a currently eligible State of Maryland vaccine phase as listed above: *

Yes

Appointment *

Confirm Appointment Date and Time *

Date

Hour Minutes AM/PM Option

Child's Date of Birth *

Date

Phone Number *

Email *

example@example.com

Address *

Street Address

Street Address Line 2

City State Code (MD, VA, PA, etc)

Zip Code

Race *

Ethnicity *

Gender *

Allergies *

Mother's Maiden Name *

Primary Care Physician

Office Fax Number

Do you have insurance (prescription / medical)? *

Yes No

Please provide either your Driver's License number or your social security number? (This is a requirement for patients that do not have insurance) *

HEALTH INSURANCE INFORMATION

FILL OUT COMPLETELY AND ACCURATELY
PLEASE PROVIDE A PHOTO OF YOUR CARD

*We will bill your insurance for the administration of the vaccine. You will NOT be charged for a co-pay or deductible*

Type of Insurance *

Private Commercial Medicaid/Medical Assistance Medicare Type option 5

Insurance Company *

If applicable, otherwise type "N/A"

Medicare ID (Alpha-numeric ID) *

If applicable, otherwise type "N/A"

Member ID Number *

RxBin (On Prescription Insurance Card)

RxPCN (On Prescription Insurance Card)

RxGroup Number (On Prescription Insurance Card)

If applicable, otherwise type "N/A"

Relationship to Cardholder *

If applicable, otherwise type "N/A"

Photo of Insurance Card (Front of Card)

Photo of Insurance Card (Back of Card)

For Vaccine Recipients:

The following questions will help us determine if there is any reason you should not get the COVID-19 vaccine today. If you answer "yes" to any question, it does not necessarily mean you should not be vaccinated. It means additional questions may be asked. If a question is not clear, please ask your healthcare provider to explain it.

Are you feeling sick/have a fever today? *

Yes No Unsure

Have you received any vaccine in the last 14 days? *

Yes No Unsure

Have you ever had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19? *

Yes No Unsure

Have you ever received a dose of COVID-19 vaccine? *

Yes No Unsure

How many doses of a Covid vaccine have you received?

0 1 2

If you have received a dose of COVID-19 Vaccine, which product did you receive?

Pfizer Moderna Another Product Janssen (J&J)

If you have received a dose of COVID-19 Vaccine, have you had an allergic reaction (e.g., hives, swelling, or respiratory distress) or severe allergic reaction (e.g., anaphylaxis) after receiving the COVID-19 Vaccine?

Yes No Unsure

Have you had an allergic reaction to another vaccine (other than COVID-19 Vaccine) or to an injectable medication? *

Yes No Unsure

Have you ever had a severe allergic reaction to something other than a component of COVID-19 Vaccine, polysorbate, or any vaccine or injectable medication? (includes food, pets, environmental, or oral medication allergies) *

Yes No Unsure

Have you ever received a passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? *

Yes No Unsure

Do you have a weakened immune system (e.g., cancer, leukemia, HIV/AIDS, or any other immune system problem) or are you taking immunosuppressive drugs/therapies? *

Yes No Unsure

Do you have a bleeding disorder, are taking a blood thinner, or have a history of Heparin-Induced Thrombocytopenia (HIT)? *

Yes No Unsure

Are you pregnant or breastfeeding? *

Yes No Unsure

Do you have a history of myocarditis or pericarditis?

Yes No Unsure

Do you have any of the following chronic health conditions? (Chronic Kidney Disease, COPD, Heart Conditions, Obesity, Sickle Cell, Smoking, Type 2 Diabetes) *

Yes No Unsure

If you do have a chronic health condition, select all that apply.

Chronic Kidney Disease COPD Heart Conditions Obesity Sickle Cell Smoking Type 2 Diabetes

CONSENT

I have read, or have had read to me, the written information regarding the vaccine(s) I will be receiving. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s) being administered and have received a copy of the current Vaccine Information Sheet. I certify that I am: (a) the parent or legal guardian of the patient and confirm that the patient is at least 5 years of age; or (b) authorized to consent for vaccination for the patient named above. I understand I am not required to accompany the child named above to the vaccination appointment and, by giving my consent below, the child will receive the vaccine whether or not I am present at the vaccination appointment. Further, I hereby give my consent to Professional Pharmacy to administer the COVID-19 vaccine. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Professional Pharmacy, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccines. Further, I agree that:

(1) The information provided is correct and all records and required information will be recorded

(2) I have read the EUA Fact Sheet provided

DISCLAIMER: I agree to wait at the pharmacy for at least 15 minutes for observation by pharmacy staff. If I have a history of anaphylaxis or a history of an immediate allergic reaction to a vaccine/injectable medication (excluding those related to COVID-19 vaccines), I agree to wait at least 30 minutes for observation by pharmacy staff.

Are you 18 years old or older? *

Yes No

By typing my full name here, I certify that: (a) I am the parent or legal guardian of the patient and confirm that the patient is at least 5 years of age (b) authorized to consent for vaccination for the patient named above. Further, I hereby give my consent to Professional Pharmacy or their agents to administer the COVID-19 vaccine. *

First and Last Name

Parent/Guardian Signature *

Clear

Type the Patient's Full name here: *

Signature *

Clear

COVID-19 Vaccine Administration Record