Consent for FLU Vaccines
Do you qualify to receive the COVID-19 Vaccine as per NY State Mandate and Guidance for Phase 1a and Phase 1b vaccination?
Yes
No (Fill out the form and join our waitlist/standby) We will call contact you if available.
Select an appointment time
Patient Name (if patient is a child, please enter the Child's Name)
*
First Name
Last Name
Home Address
*
Street Address
Apt #
City
State Initials
Zip Code
Date of Birth
*
/
Month
/
Day
Year
Patient's Age
Gender
*
Please Select
Male
Female
Race
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Ethnicity
Please Select
Hispanic or Latino
Not Hispanic or Latino
Unknown
Phone Number
*
Format: (000) 000-0000.
Mother's Maiden Name
Required for proper vaccine documentation
Primary Care Provider Name
Emergency Contact Name
Relationship to Emergency Contact
Please Select
Brother
Sister
Sibling
Mother
Parent
Father
Guardian
Spouse
Grandparent
Child
Foster child
Stepchild
Care Giver
Other
Phone Number of Emergency Contact
Format: (000) 000-0000.
Email
example@example.com
Social Security Number or Medicare Number (if available)
1. Is the person to be vaccinated sick today?
*
Yes
No
2. Does the person to be vaccinated have an allergy to eggs or to a component of the vaccine?
*
Yes
No
3. Has the person to be vaccinated ever had a serious reaction to influenza vaccine in the past?
*
Yes
No
4. Has the person to be vaccinated ever had Guillian-Barre syndrome?
*
Yes
No
Which arm would you like to get the injection on
Left Arm
Right Arm
COVID-19 Vaccine Screen Questions
Rows
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?
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?
Consent (check each box below after reading and prior to signing the form)
Rows
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 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, 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.
I understand that I will be receiving the vaccination at no cost to me.
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 Insurance Card
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For uninsured patients, please select at least one of the following that you will bring with you to your appointment.
Social Security Number
State identification number and state of issuance
Driver's license number and state of issuance
Please Upload Supporting Uninsured Document
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Patient signature (Parent or guardian, if minor):
Date Signed
/
Month
/
Day
Year
Date
Pharmacist Name
First and Last Name
Pharmacist Signature
Immunizer Name
First and Last Name
Immunizer Signature
Lot Number
Expiration Date:
Vaccine Manufacturer
Moderna Vaccine
Pfizer Vaccine
Pharmacy Name
Pharmacy NPI
*
Calculation
Please take a picture of your front of your prescription insurance card if available. (By sending us your insurance card now will also reduce your wait time in the pharmacy) Please also bring in original at time of vaccination.
Back of insurance card
PLEASE BRING YOUR INSURANCE CARD WITH YOU INTO THE PHARMACY.
Submit
Should be Empty: