Covid Vaccine In store for adults and kids (12 y/o and up)

COVID-19 Vaccine Consent Form

COVID-19 Vaccine Appointment - Pfizer, Pfizer Bivalent, Moderna, and Moderna Bivalent, Vaccine Provided by The Medicine Shoppe of Shillington PA (Reading PA area).
Rules to receive the Covid Vaccines Appointment - Pfizer, Pfizer Bivalent, Moderna, and Moderna Valent.

Location: The Medicine Shoppe of Shillington 101 W. Lancaster Ave Shillington, PA 19607

Date/Day: Monday to Friday 10am to 5:45pm and Saturday 9am to 1pm

Pfizer Bivalent: Age 12 and older for Booster ONLY. Eligibility is 2 months after lastest dose.

Moderna Bivalent: Age 12 and older for Booster ONLY. Eligibility is 2 months after lastest dose.

Pfizer: - Age 12 and older for 1st and 2nd dose ONLY.

Moderna: - Age 18 and older for 1st and 2nd dose ONLY.
- Once you hit “Submit” you will be prompted to print a form and bring the form with you to your appointment. It is very important that you bring this form with you to the event as it is required for vaccination. If you are unable to print the form, someone will assist you when you arrive at the Pharmacy.
- Bring your Pharmacy/Prescription insurance card if this is the 1st time you getting a vaccine from the Medicine Shoppe of Shillington. If your on medicare, please bring your medicare part B Card (Red, white and blue card).
- Bring your vaccination card for 2nd or 3rd (Booster) shot.
- Dress appropriately for the vaccine in order to allow your upper arm to be easily accessed.
- Click here to Download and/or View the COVID-19 Vaccine EUA Facts Sheet.
Select your dose? 1st or 2nd or Booster*
Select your desire 1st and 2nd COVID-19 Vaccine*
Select your desire COVID-19 Vaccine booster*
Flu vaccine can be administered together with COVID-19 Vaccine. Would you like to get your Flu Shot as well?
Select an appointment time.*
Did you received any Covid vaccine from The Medicine Shoppe of Shillington or at Governor Mifflin School? (This will prevent us from making duplicate profile)*

YesNo
Are you on Medicare?*

YesNo
Most insurances are covering for free up to 8 at-home COVID tests per month. Would you like to get At-Home COVID-19 OTC tests?
Please enter your Medicare Number from medicare Part A&B Card (Red, White and Blue card). We NEED the original Medicare number NOT your advantage plan. *
Email*
example@example.com
LEGAL First Name*
Middle Name
LEGAL Last Name*
Vaccine Recipient Physical Address*

Street Address

Street Address Line 2

CityState Initials

Zip Code
Date of Birth*

MonthDayYear
Gender at birth*
Race*
Ethnicity*
Vaccine Recipient Phone Number*
Mother's Maiden Name
Required for proper vaccine documentation

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?
11. Are you pregnant or breastfeeding?

COVID-19 Vaccine Manufacturer for the first dose received (do not complete if you selected "no" to #2 above.)
Required if you selected "Yes" to #2
Date of last Covid-19 vaccine dose (do not complete if you selected "no" to #2 above.)

MonthDayYear
Required if you selected "Yes" to #2
Select your dose? 1st or 2nd or 3rd(Booster)*

1st (First)2nd (Second)Booster

Consent (check each box below after reading and prior to signing the form)*

	Check each box
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet (the Pfizer Fact Sheet is available after clicking submit), a copy of which I was provided with this Consent Form. I have had a chance to ask questions that were answered to my satisfaction. 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 Form.
I understand that at this time, the COVID-19 vaccine requires 2 doses given 21-28 days apart depending on the manufacturer. If this is my second dose, I will bring my vaccine card with me to be completed.
I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.

Which arm would like the vaccine?

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

Clear
Date Signed ( We will ask for another signature on the day of vaccine)

MonthDayYear
Date
Should be Empty:

COVID-19 Vaccine Consent Form