Lopez Island Pharmacy New Covid Vaccination Questionnaire COVID Sept. 2023 Ver 1.8

Lopez Island Pharmacy (360) 468-2616

Fax (360)468-3825

New Covid-19 Vaccination 2025-2026 Consent Form

Rev: 9/4/2025 HIPAA Compliant ver. 2.5

** Clinic Use ONLY ** Forehead Temp.: ________F
We ONLY use Moderna and recipients must be ages 18 or older.

Pfizer Covid vaccine is NOT currently available at Lopez Island Pharmacy.
I am age 18 or older?*

YesNo
Do you already have an appointment date and time scheduled for a Covid-19 Vaccination?*

YesNo

If you do NOT have an appointment for COVID-19 vaccine do NOT fill out a consent form.

Only fill out this form if you have an appointment ALREADY scheduled.
Patient Name (Who is receiving the vaccination)*

First NameMiddle NameLast NameSuffix
Birth Date:*

MonthDayYear
Date
Sex at birth*

MaleFemale
Are you under age 65?*

YesNo
Are you pregnant or breastfeeding, or do you plan to become pregnant?*

YesNo
What Trimester are you in, or breastfeeding?
Phone Number*
Mobile Phone
Email
example@example.com
Race?*
Ethnicity?*

I do not have any insurance, including but not limited to Medicare, Medicaid, OR any other private or government-funded health benefit plan.

Yes (You do NOT have any insurance)No
Enter at least one of the following, you MAY enter more than one if you choose.
Social Security Number (WITHOUT DASHES ex. 123456789)
Driver's License Number and State of Issuance
Enter your Drivers License Number and the State where it was issued
Is Lopez Island Medical Center your "Primary Provider"?*

YesNo
Then please enter your "Primary Care" provider name and phone number.
Enter your Primary Care provide and phone number.

Acknowledgements

I made the choice to get the COVID-19 vaccine on my own and freely. I know I have the option to refuse the vaccine. I ask that the vaccine be given to me, or to the person named above for whom I can make this request. I was given the Vaccine Information Sheet for this vaccine. The information sheet has information about side effects and adverse reactions. I read or had read to me the information provided about the COVID-19 vaccine on the infomation sheet. I understand that my information will be stored electronically in the Washington Immunization and Information System (WAISS)

I know that if I have a severe allergic reaction, including difficulty breathing, swelling of my face and/or throat, a fast heartbeat, a bad rash all over my body or dizziness and weakness I should call 9-1-1 or go to the nearest hospital. I know I can call my health care provider if I have any side effects that bother me or do not go away.
Authorization to Request Payment:

I authorize the organization providing my vaccine to release information and request payment. I certify that the information given by me in applying for payment under Medicare or Medicaid or the HRSA COVID-19 Program for Uninsured Patients, is correct. I authorize release of all records to act on this request. I request that payment of authorized benefits be made on my behalf.

Disclosure of Records: I understand the organization providing my vaccine may be required to or may voluntarily disclose my vaccine-related health information to my primary care physician, my insurance plan, health systems and hospitals, and state or federal registries or other public health authorities, for purposes of treatment, payment or health care operations. I also understand the organization providing my vaccine will use and disclose my health information as described in its Notice of Privacy Practices which I may receive upon request or find on its website . If I am an employee of Lopez Island Pharmacy(LIP) I understand that it will keep records of this vaccination for me in Pioneer Pharmacy Database and may keep my vaccination records in LIP's Electronic Medical Records sytem employee occupational health records, to the extent required or permitted by law. Lopez Island Pharmacy does not discriminate.
All vaccinations are submitted to the Washington State Health Department Vaccination Database UNLESS you specifically opt out.*

I consent to this vaccination being submitted to the Department of Health DatabaseI do NOT consent to my vacciantion being sent to the Department of Health Database
Patient Signature *

Clear
Date*

MonthDayYear
Date
Press "SUBMIT" to finish...

If you receive a large green check mark after clicking the "Submit" button and a "Thank You!" message, you have completed this form

Forehead Temperature: ____________ F.

Lot Number: _____________ Expiration Date: ___/___/___ *

Administration Date: ___/___/___

Route: IM ONLY for Moderna

Admin Site: Left Deltoid Right Deltoid Other:________

Date this record was entered into WA Register: __________________

Vaccine Administered by:____________________________

Notes:

We only carry the Moderna vaccination, and you must be 18 years or older.

Have your appointment already scheduled, if not please schedule your appointment first and then come back to this form.
Should be Empty: