COVID Bivalent Consent Form Rev Apr 2023

Do you feel sick today?*

YesNoDon't Know

Have you had COVID-19 within the last three months?*

YesNoDon't Know

Have you received any immunizations in the past 4 weeks?*

YesNoDon't Know

Please list immunization(s) received:*

Do you have a history of an immune-mediated syndrome defined by thrombosis and thrombocytopenia, such as heparin-induced thrombocytopenia (HIT)?*

YesNoDon't Know

Do you have a history of thrombosis with thrombocytopenia syndrome (TTS)?*

YesNoDon't Know

Have you been with Multisystem Inflammatory Syndrome (MIS-C) or MIS-A) after a COVID-19 infection?*

YesNoDon't Know

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 or smell, sore throat, nausea, vomiting or diarrhea?*

YesNoDon't Know

Do you have any allergy to any food, medication, or vaccine?*

YesNoDon't Know

Please specify allergy:*

Have you ever had a serious reaction or fainted after receiving any vaccination?*

YesNoDon't Know

Do you carry an EpiPen?*

YesNoDon't Know

Do you have a bleeding disorder or take a blood thinner?*

YesNoDon't Know

Have you ever had a seizure disorder, brain disorder, or Guillain-Barre Syndrome?*

YesNoDon't Know

Do you have a weakened immune system (i.e., HIV infection, cancer), history of a transplant, or take immunosuppressive drugs or therapies?*

YesNoDon't Know

Do you have a history of myocarditis or pericarditis?*

YesNoDon't Know

Have you received hematopoietic cell transplant (HCT) or CAR-T cell therapies since receiving COVID-19 vaccine?*

YesNoDon't Know

During the past year, have you received a transfusion of blood or blood products or been given a medicine called immune (gamma) globulin or an antiviral drug?*

YesNoDon't Know

Do you have a long-term health problem with heart, lung, kidney, diabetes, asthma, no spleen, cochlear implant, anemia or a blood/bleeding disorder?*

YesNoDon't Know

Please specify health problem:*

FOR WOMEN: Are you pregnant or are you planning on becoming pregnant during the next month?

YesNoDon't Know

For children ages 2-4: Has a healthcare provider told you that the child had wheezing or asthma in the past 12 months?*

YesNoDon't Know

For children/teens: Has the child, sibling, or parent had a seizure; has the child had brain or other nervous system problems?*

YesNoDon't Know

For those 50+: Have you had a shingles vaccination or been diagnosed with shingles in the last 12 months?*

YesNoDon't Know

For those 65+: Have you ever had a pneumococcal vaccination?*

YesNoDon't Know

Pfizer Bivalent EUA

Moderna Bivalent EUA

Notice of Privacy Practices

Acknowledgements*

I understand the benefits and risks of the vaccination(s) as described in the Vaccine Information Sheet (VIS) or Emergency Use Authorization (EUA), a copy of which I was provided with this Consent & 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 & Release.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 & 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.I attest that the answers provided here are accurate to the best of my knowledge.

Signature of Person to Receive Vaccine & VIS

Clear

Date

Parent/Guardian Name

Relationship to patient

Insurance Information

I hereby authorize the pharmacy to bill my Insurance on my behalf for the immunizations and receive paymentIf you do not have insurance, please provide your Social Security Number or Driver's License.

Select your insurance

MedicaidMedicare Part BPrivate Insurance

Medicaid Provider

Policy/Member ID #*

Medicaid #

Group #

Subscriber ID #

Responsible Party

Policy Holder's Date of Birth

Date

Insurer

Subscriber ID

Bin #

PCN

Group #

Social Security Number

Driver's License

Optional: Upload a photo of your insurance or Medicare card

After submitting, you will be redirected to schedule your appointment. Please make sure to confirm your appointment so we save your spot on our schedule. If you are scheduling for COVID-19 and another vaccine, please only make the COVID-19 appointment. If there are no appointments available for the vaccine you need, please check back.

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.

Consent Form and Screening Questionnaire for COVID-19

AGES 6+

AGE 5

AGES 6mo-4yr

REASONS TO STOP

Questionnaire

Signatures