COVID-19 Vaccine form - Updated 9/9/22

Dowd Drug Covid Vaccine Consent Form

* Please fill out the required details below
Patient's Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Care Doctor
Effective 9/2/22 the following has been updated:

The U.S. Food and Drug Administration amended the emergency use authorizations as follows:

Moderna COVID-19 Vaccine, Bivalent authorized for use in people 18 years and older.

Pfizer-BioNTech COVID-19 Vaccine, Bivalent authorized for use in people ages 12 years and older.

Authorized as single booster dose administered at least 2 months after either:
- Completion of primary vaccination with any authorized or approved monovalent COVID-19 Vaccine, or
- Receipt of the most recent booster dose with any authorized or approved monovalent COVID-19 vaccine
Primary series remains the same. Ages 12+ can receive the Pfizer-BioNTech COVID-19 Vaccine at Dowd Drug and Ages 18+ can receive the Moderna COVID-19 Vaccine. Two doses of each are required in the primary series.
What dose of COVID-19 vaccine will this be?
What vaccine do you prefer? Moderna is only approved for 18 and older and Pfizer is for 12 and up.
When did you receive your first dose?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
When did you receive your last dose of the COVID-19 vaccine? (must be at least 2 months ago)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Please Select the Correct Option Below

Rows	YES	NO	Don't Know or N/A
In the past two weeks, have you tested positive for COVID-19 or are currently being monitored for COVID_19?
In the past two weeks, have you had a known exposure with anyone who tested positive for COVID-19?
Have you had a new onset of fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste of smell, sore throat, nausea, vomiting or diarrhea?
Do you feel sick today?
Do you have an allergy to medications, foods, or any vaccines (eggs, gelatin, thimerosal, neomycin, gentamicin, latex, aluminum, preservatives, bakers yeast, etc)
Do you carry and EpiPen?
Have you received COVID-19 monoclonal antiboties or convalescent plasma in the last 90 days?
Have you ever had a serious reaction or fainted after receiving a vaccination?
Have you ever had a seizure, brain disorder, or guillain-barre syndrome?
Have you received another vaccine in the last 14 days?
Have you had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?
Do you have a bleeding disorder or are you taking a blood thinner?
For Women: Are you pregnant or are you planning on becoming pregnant during the next month?

Please Specify the allergy from Q2:
Section IV. Signatures

I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Pfizer found here and Moderna found here , a copy of which I was provided with this Consent and Release. 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 and Release.
Signature of Person to Receive Vaccine & EUA/VIS (or signature of parent/guardian if patient is
I have received a copy of the notice of Privacy Practices. I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.
Signature of Ackowledgement of Notice of Privacy Practices: If using a desktop computer, click with your mouse to sign.
Type a question

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

Rows	Check One
If INSURED, check this box attesting to bring in your prescription and medical insurance cards for your appointment. By selecting this, you also authorize the pharmacy to bill your insurance on your behalf for the immunization - understanding you will not incur any costs.
If UNINSURED, you must chekc this box to attest that 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 goverment-funded benefit plan.

Appointment
By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.
**** For Pharmacy Use Only*****

Rows	Which Dose is this	Route	Date Dose Administered	Vaccine Maufactuer	Dosage	Lot Number	Expiration
COVID_19

Signature of Pharmacist administering Vaccine
Should be Empty:

Dowd Drug Covid Vaccine Consent Form