COVID VACCINE

NEW VACCINE

RECOMMENDATIONS

CDC’s new recommendations allow an additional updated (bivalent) vaccine dose for adults ages 65 years and older (at least 4 months from last covid vaccine) and additional doses for people who are immunocompromised (at least 2 months from last covid vaccine) .
This form will be used only for the new updated bivalent booster for now. Please call if you would like to schedule a different covid vaccine. Thank you!

Section 1: Vaccine Recipient Information

Name: *

Date of Birth:*

Age:*

Phone Number:*

Email Address:

Primary Healthcare Provider:

Race: *

Address:*

Street Address (NO PO BOXES)

Street Address Line 2

CityState

Zip Code

Ethnicity: *

Gender*

M = Male, F = Female, T = Transgender, U = Unknown

What vaccine would you like to receive?*

Moderna Bivalent Booster: 65+ and/or immunocompromisedPfizer Bivalent Booster: 65+ and/or immunocompromised

How would you like to receive the covid vaccine?*

Inside pharmacyOutside in vehicle - unless raining: inside

PLEASE BRING YOUR COVID VACCINATION CARD TO YOUR APPOINTMENT.

THANK YOU!

Section 2: COVID-19 Pre Vaccination Assessment:

The following questions will help us determine if there is any reason you should not get the COVID-19 vaccine today. If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions may be asked. If a question is not clear, please ask your healthcare provider to explain.

Please answer the following:*

	Yes	No	Don't know
1. Are you feeling sick today?
2. Have you ever had a severe allergic reaction (e.g. anaphylaxis) to something including eggs? For example, a reaction for which you were treated with epinephrine or EpiPen, or for which you had to go to the hospital?
3. In the last 90 days, have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as a treatment for COVID-19?
5. In the last 14 days, have you tested positive for COVID-19?
6. Are you immunocompromised? examples: HIV infection, cancer, or taking immunosuppressive drugs
7. Do you have a bleeding disorder or are you taking a blood thinner?
8. Are you pregnant or breastfeeding?
9. In the last 4 months, have you had a COVID Vaccine?

Please pick an appointment slot for your vaccination (TUESDAY AND THURSDAY)*

Prescription insurance (may skip if previous shot at pharmacy):
ID #: RX BIN:
RX GROUP (GRP): RX PCN:

MEDICARE PATIENTS:
If medicare, please provide ID number (Red, White, Blue card):
MEDICARE NUMBER HERE

Section 3: Consent

I have read or have had explained to me the information provided in the Emergency Use Authorization for bivalent pfizer (HERE) or for bivalent moderna (HERE). I have had a chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of COVID-19 vaccine and ask that the vaccine be administered to me or the person named above for whom I am authorized to make this request.

Signature:*

Clear

COVID Vaccine Consent Form