Episcopal 01.02.2022 Vaccines (114 inbox)

COVID-19 Vaccine Registration and Consent Form
Location: Episcopal School of Dallas

On-Campus Clinic
COVID-19 Vaccination Clinic

Pfizer-BioNTech, Johnson & Johnson, and Moderna

Sunday, January 2nd, 2022. 4:00 - 6:00 PM

Please complete this registration prior to the vaccination clinic. Your answers will be reviewed at the time of your appointment by our medical staff.

A registration and consent must be completed for each vaccination received. Thank you for taking the time to pre-register.

Vaccinations and all medical services administered by Carpe Diem Health PLLC, a Texas COVID-19 vaccination provider.
Please select a COVID-19 vaccination *

Pediatric dose (5 -11) Pfizer Bio-NTech shot 1 Pediatric dose (5-11) Pfizer Bio-NTech shot 2 Adult dose (12 and up) Pfizer Bio-NTech shot 1 Adult dose (12 and up) Pfizer Bio-NTech shot 2 Adult dose (12 and up) Pfizer Bio-NTech booster (16 years and older;given 6 months after second dose of mRNA vaccine) Moderna shot 1 (0.5 mL dose) Moderna shot 2 (0.5 mL dose) Moderna booster (0.25 mL dose) (18 years and older, given 6 months months after second dose of mRNA vaccine) Johnson and Johnson Johnson and Johnson booster
PATIENT INFORMATION
Vaccine recipient name *

First Name Middle Name Last Name Suffix
Vaccine recipient address *

Street Address

Street Address Line 2

City State Initials

Zip Code
Date of birth *

Month Day Year
Gender *
Race
Ethnicity
Vaccine recipient phone number (or Guardian if under 18) *
Vaccine recipient email (or Guardian if under 18) *
example@example.com
Emergency contact name *
Relationship to emergency contact *
Phone number of emergency contact *

PRE-VACCINATION QUESTIONS FOR REVIEW - TO BE COMPLETED BY VACCINE RECIPIENT, or ON BEHALF OF THE RECIPIENT BY THE GUARDIAN IF UNDER 18. *

	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 a component 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? Discuss at the time of your appointment (Shingrix and Pneumovax recipients should wait 21 days before a COVID-19 vaccination).
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?

If this will be your second dose, or a booster dose of a COVID-19 vaccine, what was the date of your most recent vaccination?

Month Day Year
INSURANCE STATUS

The vaccine is available to everyone at no cost, whether insured or uninsured. Please check one of the following. *

	Check one
If INSURED, check this box, and enter your plan information in the boxes below. By selecting this, you authorize Carpe Diem Health PLLC to bill your insurance on your behalf for administration of your COVID-19 immunization. You will not incur any costs. Please bring your card to your appointment.
If UNINSURED, you must check this box to attest that the the following information is true and accurate: I do not have any insurance, including but not limited to, Medicare, Medicaid, or any other private or government-funded benefit plan. You will not incur any costs.

Primary Insurance Information

	Please Enter All Applicable Fields
Insurance Company
Plan Name
Member Name / Insured's Name
Member ID/ Insurance ID
Group Number
Plan Start Date

If UNINSURED, please choose one of the following forms of identification and provide the information in the box below. If none of the following are issued, check NO ID.

Social Security Number, State Identification number, or Driver's License number. No ID
If UNINSURED, please enter either your Social Security Number, State ID or Driver's license below. For State ID or Driver's License, also provide in which state it was issued.
CONSENT FOR VACCINATION - To be completed by the vaccine recipient, or the Guardian if under 18 years of age

Check each box below after reading, and prior to signing the consent 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, a copy of which was provided to me upon completion of this Consent Form. (PDF Fact Sheet links for each manufacturer are provided below). I understand I will have the opportunity to ask questions at the time of my vaccination. 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 (the "Guardian").
I understand that at this time, the Pfizer BioNTech COVID-19 vaccine requires 2 doses given approximately 21 days apart, the Moderna COVID-19 vaccine requires 2 doses given approximately 28 days apart. Johnson and Johnson is a one-shot vaccination. If this is my second dose, or a booster dose, I will bring my vaccine card or prior shot record with me to be completed and to verify dates.
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.
I understand that I will be receiving the vaccination at no cost to me.

Signature of consenting vaccine recipient, or the Guardian if under age 18. *

Clear
Full name of consenting Guardian for age < 18

First Name Middle Name Last Name Suffix
Relationship to minor receiving vaccination

Parent Legal Guardian Other
Date Signed *

Month Day Year
Date
Below are Patient Fact Sheets from each COVID-19 vaccine manufacturer. Please review the fact sheet associated with your scheduled vaccination.

If you have any questions, please ask at the time of your vaccine, or by calling Carpe Diem Health PLLC (972) 846-9550 at any time.

Dr. Sadeh is available for questions by email as well at Dr.Chris@DocDashDFW.com

Pfizer-BioNTech COVID-19 Vaccine Fact Sheet

Moderna COVID-19 Vaccine Fact Sheet

Janssen COVID-19 Vaccine Fact Sheet

When your vaccination is complete, you will receive the CDC COVID-19 Vaccination Record Card. If this is your 2nd or 3rd COVID-19 vaccination, please bring your CDC vaccination card and we will update it.

Please submit your registration using the button below.

COVID-19 Vaccine Registration and Consent Form

Location: Episcopal School of Dallas