Glen Montessori School: Pfizer Covid-19 Vaccine Clinic Age 12+

Pfizer Covid Vaccine Clinic Age 12+ provided by Adzema Pharmacy and Palmer Pharmacy

This form is for those wishing to be vaccinated (booster, 1st and 2nd doses will be available, note must be 18+ for booster) at Glen Montessori School at 950 Perry Hwy, Pittsburgh PA 15237 on Saturday, December 11, 2021 - appointment necessary. Please accurately complete all parts of this form. Pfizer Covid-19 vaccinations are available for anyone 12 years and older. Please complete a separate entry for each person. **Note the following only applies if you received your first dose. If you received your first dose on November 20th's clinic you will automatically be scheduled to receive your second dose exactly 21 days later in the same appointment slot on December 11, 2021, you will not need to complete another form**
Name of Person receiving vaccine*

First NameLast Name
Age
Date of Birth*

MonthDayYear
Date
Name of Parent if Minor (under 18)

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number*
Please enter a valid phone number.

Information on the risks and benefits of the Pfizer BioNTech COVID-19 Vaccine

The Pfizer-BioNTech COVID-19 Vaccine may prevent the person vaccinated from getting COVID-19. There is no U.S. Food and Drug Administration (FDA)- approved vaccine to prevent COVID-19. However, the FDA has authorized the emergency use of the vaccine to prevent COVID-19 vaccine in individuals 16 years of age and older under the Emergency USe Authorization (EUA). The Pfizer BioNTech COVID-19 Vaccine is administered as a 2 dose series, 3 weeks apart, into the muscle. The vaccine may not protect everyone. Side effects that have been reported with the Pfizer-BioNTech COVID-19 vaccine include injeciton site pain,tiredness, headache, muscle pain, chills, joint pain, fever, injection site swelling, injeciton site readness, nausea, feeling unwell, and swollen lymph nodes. There is a remote chane that Pfizer-BioNTech COVID-19 vaccine could cause a severe allergeic reaction. A severe allergic reaction would usually occure within a few minutes to one hour after getting a dose of the Pfizer -BioNtech Covid -19 vaccine. For this reason, a vaccine provider may ask the person receiving the vaccine to stay at the place where they recieve the vaccine for monitoring after vaccination. Signs of severe allergic reaction include difficulty breathing, swelling, of the face and throat, a fast heartbeat, and a bad rash all over the body. The Pfizer-BioNTech COVID-19 Vaccine "Fact Sheet for Recipients and Caregivers" is available at https://www.fda.gov/media/144414/download.

Consent For Vaccination: I have reviewed the information on risks and benefits of the Pfizer-BioNTech COVID-19 vaccine above and understand the risks and benefits. In providing my consent below, I agree that: I have reviewed this consent form, and I understand that the "Fact Sheet for risks and benefits of the Pfizer-BioNTech COVID-19 vaccine. If I have health insurance I give permission for my insurance company to be billed for the costs of administering the Pfizer-COVID-19 Vaccine. The goverment is paying for the Pfizer-BioNTech COVID-19 Vaccine itself, and I will not be billed for that portion of the cost of my immunization. I understand that as required by state law, all immunizations will be reported to the appropriate state immunization registration system.

I GIVE CONSENT for pharmacists to give me the Pfizer-BioNTech COVID-19 Vaccine and have reviewed and agree to the information included in this form. (If this consent is not signed, dated and returned, you will not be vaccinated.)

Consent for Minor's Vaccination: I have reviewed the information on risks and benefits of the Pfizer-BioNTech COVID-19 vaccine above and understand the risks and benefits. In providing my consent below, I agree that: I have reviewed this consent form, and I understand that the "Fact Sheet for risks and benefits of the Pfizer-BioNTech COVID-19 vaccine. I have legal authority to consent to have the child named above vaccinated with the Pfizer-BioNTech COVID-19 Vaccine. I understand I am required to be present at the first vaccination appintment, but not required to accompany the child named above to their follow-up vaccination appointment and that, by giving my consent below, the child will receive the Pfizer-BioNTech COVID-19 Vaccine whether or not I am present at the vaccination appointment. If I have health insurance that covers the child named above. I give permission for my insurance company to be billed for the costs of administering the Pfizer-COVID-19 Vaccine. The goverment is paying for the Pfizer-BioNTech COVID-19 Vaccine itself, and I will ot be billed for that portion of the cost of my immunization. I understand that as required by state law, all immunizations will be reported to the appropriate state immunization registration system.

I GIVE CONSENT for the child named at the top of this form to get vaccinated with the Pfizer-BioNTech COVID-19 Vaccine and have reviewed and agree to the information included in this form. (If this consent is not signed, dated and returned, the child will not be vaccinated.)
Signature of Adult receiving vaccine or Signature of legally authorized individual if minor (under 18 years of age)*

Clear
Date*

MonthDayYear
Date
Insurance Carrier i.e. Highmark, UPMC, etc.*
Policy Number (ID Number)*
Group Number *
Date of Birth of Primary Insured Individual

MonthDayYear
Date
If you are a spouse or dependent on the policy, please write the name of the primary insured person and your relation.
Take Photo of your insurance card Front
Take Photo of your insurance card Back

Pick appointment time. Please note we will use the same time to automatically schedule you for your follow up appointment to complete the vaccination series on Saturday December 11th*
Should be Empty:

Pfizer Covid Vaccine Clinic Age 12+ provided by Adzema Pharmacy and Palmer Pharmacy