COVID-19 & Flu Vaccine Screening Form

Do you have a condition that puts you at high risk for severe outcomes from COVID-19 virus? See list of health conditions and risk factors below.*

Yes, the patient is eligibleNo, remove Covid-19 Vaccine

Select an appointment time*

Vaccine Recipient Name*

First NameMiddle NameLast Name

Vaccine Recipient Physical Address*

Street Address

Apt #

CityState Initials

Zip Code

Maryland County*

Date of Birth*

Gender at birth*

Race*

Ethnicity*

Email*

example@example.com

Vaccine Recipient Phone Number*

COVID-19 Vaccine Screen Questions*

	Yes	No
1. Are you feeling sick or anxious today?
2. Have you ever felt dizzy or faint before, during or after a shot?
3. Have you ever had an allergic reaction to a component of the vaccine, including polyethylene glycol (PEG), Polysorbate or allergy to Latex?
4. 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, eggs, pet, environmental, or oral medication allergies.
5. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?
6. Do you have a weakened immune system caused by something such as HIV infection or cancer or had Guillain-Barre-syndrome or do you take immunosuppressive drugs or therapies?
7. Do you have a bleeding disorder or are you taking a blood thinner? Do you previously diagnosed with Multisystem Inflammatory Syndrome (MIS-A or MIS-C) or have a history of myocarditis or pericarditis?

Allergic Reaction Defined: This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.

Which arm would you like to get the injection on*

Left ArmRight Arm

Vaccine Manufacturer

Comirnaty 2025-26 Age 12 and Up (Pfizer)Spikevax 2025-26 Age 12 and Up (Moderna)mNexSpike 2025-26 Age 12 and Up (Moderna)Pediatric Moderna Age 5 and UpPediatric Pfizer Age 5 and Up

Vaccine*

Covid and Flu vaccineCovid Vaccine OnlyFlu vaccine Only

Vaccine Age 50 plus ONLY

Pneumonia (Age 50+)RSV (Age 50+ with Health conditions)Shingrix (Age 50+)

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/Moderna 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, I have qualifying health conditions and/or risk factors Cancer Chronic heart disease Chronic lung disease including cystic fibrosis Kidney disease Diabetes Dementia or a neurologic condition Chronic liver disease Blood disorders Body mass index greater than 25 Past or current smoker HIV or tuberculous infection Weakened immune system Pregnancy Substance use disorders Mental health conditions Physically inactive Solid organ or blood stem cell transplant Any other conditions or situations that places you at higher risk of severe illness from COVID-19 (consult your pharmacist or medical provider if you need help) . I give consent to receive text messages regarding immunization service.
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 if my insurance rejects, for any reason I will be billed for vaccine and administration cost for Covid commerical vaccine. I authorize to bill up to eight covid test kits to insurance for my personal use.

The vaccine is available to anyone no matter if insured or uninsured. Please check only one of the following.*

If INSURED, check this box attesting to bringing in your prescription and medical insurance cards for your vaccine appointment. By selecting this, you are also authorizing the pharmacy to bill your insurance on your behalf for the immunization – understanding you will not incur any costs.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.

Please Upload Pharmacy Insurance Card *

For uninsured patients, please select at least one of the following that you will bring with you to your appointment.

Social Security NumberState identification number and state of issuanceDriver's license number and state of issuance

Please Upload Supporting Document

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

Date Signed

Date

Immunizer Name

First and Last Name

Immunizer Signature

Lot Number

Expiration Date:

Pharmacy Name

Pharmacy NPI*