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I need my FIRST COVID vaccination
I am over 65 and need an additional dose.
I am immunocompromised and need an additional dose.
A child under 6 years of age starting or completing their pediatric COVID series.
I would like a non-mRNA (Novovax or Janssen)
Which COVID vaccination would you like to receive for your dose?
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Janssen
Moderna
Novavax
Pfizer
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Vaccine Recipient Name
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First Name
Middle Name
Last Name
Date of Birth
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Vaccine Recipient Phone Number
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Social Security Number
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Required for billing of administration to insurance (there is no out-of pocket cost to you)
Vaccine Recipient Physical Address
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Street Address
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State Initials
Postal / Zip Code
Ethnicity
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Hispanic or Latino
Not Hispanic or Latino
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Race
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American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
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Gender at birth
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Male
Female
Mother's Maiden Name
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Required for proper vaccine documentation
Primary Care Provider Name
Emergency Contact Name
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Relationship to Emergency Contact
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Phone Number of Emergency Contact
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COVID-19 Vaccine Screen Questions
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Yes
No
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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 28 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? in the last 3 months?
8. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?
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?
12. Do you have dermal fillers?
13. Do you have a history of myocarditis or pericarditis?
14. Do you have a history of Guillain-Barre Syndrome (GBS)?
15. Have you been diagnosed with Multisystem Inflammatory Syndrome after a COVID19 infection?
16. Do you have a long-term health problem such as heart disease, lung disease, liver disease, asthma, kidney disease, metabolic disease (e.g., diabetes) anemia or other blood disorder?
17. Do you have a history of heparin-induced thrombocytopenia (HIT) or thrombosis with thrombocytopenia syndrome (TTS)?
18. Have you previously received a COVID-19 vaccine before or during hematopoietic cell transplant (HCT) or CAR-T-cell therapies?
If you have allergies to medications or other products, please list those here.
Consent (check each box below after reading and prior to signing the form)
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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 with insurance, including but not limited to Medicare, Medicaid, or any other private or government-funded benefit plan and to anyone without insurance.
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.
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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
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):
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