FPCW Clinic 10/1/23 Consent Form

First Presbyterian Church of Westminster
Fall 2023 Vaccine Clinic
Sunday October 1, 2023
11:30am - 1:00pm
Jenkins Lounge

Please READ ALL of the information below.

WHAT TO BRING

Your Prescription Insurance Card(s) and/or Medicare (Red, White, Blue) Card if 65 +

WHAT TO WEAR

Please wear a short sleeve shirt for the pharmacist to administer the vaccine in your upper arm. Layering on top is fine if you tend to get chilly.

WHEN YOU ARRIVE

Because you have completed your consent form ahead of time, head to the check-in table outside Jenkins Lounge. You will be notified if there are any insurance questions upon check-in.
Please wait in the hallway in the designated chairs until your name is called by the pharmacist to receive your vaccine. Vaccinations will be administered in private in Jenkins Lounge.

Uninsured/Not-Covered patient pays CASH OR CHECK ONLY (flu only):
--> $30 Regular Quadrivalent Flu Vaccine
--> $85 High-Dose Quadrivalent Flu Vaccine (ages 65 and older)

Vaccine administration is subject to availability, and will be given on a first-come, first serve basis while supplies last. To ensure supply, please sign up by Monday September 25th (either online OR hard copy).

Please note: New Fall 2023 COVID-19 vaccines will likely be available later this Fall. Stay tuned for the announcement of a potential 2nd church vaccine clinic date to include COVID-19 vaccines.

Questions? Call or text Min-li Cary, PharmD at (410) 596-4564.

Thank you for trusting us with your health!

Name*

First NameLast Name

Gender*

FemaleMaleOther

Date of Birth*

Date

Gender

Today's Date

Date

Age

Vaccine(s) Requested*

Type of Influenza Vaccine Requested*

High-Dose Flu; ages 65 +Standard Dose Flu; ages 3 +

Type of COVID-19 Vaccine Requested*

ModernaPfizer; ages 12 +Pediatric Pfizer; ages 5-11

Type of Pneumonia Vaccine Requested*

Prevnar20Pneumovax23Not sure; consult with Pharmacist for best recommendation

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Primary Phone Number*

Please enter a valid phone number.

Email*

Confirmation EmailReenter email address for confirmation

Mother's Maiden Name

Primary Care Provider Information*

I do not have a primary care providerName of Primary Care Provider

Primary Care Provider Phone Number

Please enter a valid phone number.

Race*

Ethnicity*

Hispanic/LatinoNon Hispanic/LatinoDo not wish to answer

Insurance Type: *Enter as much information as possible to ensure smooth data entry and processing; can select more than one if applicable**

MedicareOther Private Insurance or Medicare Part D PlanMedicaid/Medical AssistanceNo Insurance

Patient Medicare ID Number*

XXXX-XXX-XXXX; as seen on your Red, White, and Blue card

Patient Insurance Information:

RX BIN #*
RX PCN #*
Member/Subscriber ID#*
RX Group #*

Medicaid ID # (11 digits long)*

Please upload a picture of the front AND back of your prescription and medical insurance card(s). You may have one card listing both types of coverage. This field is not required, so if you are unable to upload a copy of the card, then please bring your card(s) with you at the time of your vaccination.

Front of Insurance Card(s):

Back of Insurance Card(s)

Please review the following Screening Questions. These will be reviewed with a pharmacist at the time of the vaccination and the patient will be given an opportunity to ask questions. If you would like additional information or have a condition below that indicates you should speak with a pharmacist prior to your appointment, please call 410-744-5959 and press option 3. Then ask to speak with a pharmacist about vaccine information. *

	Yes	No	Unsure
Do you feel sick today?
Do you have any long-term health conditions? (examples: Diabetes, Asthma, COPD, Anemia, Kidney Disease) - in many cases, this question is used to help identify other vaccines that may be recommended for you.
Do you have an allergy to medications, food, latex, or vaccines? (examples: eggs, gelatin, thimerosal) - this is important information as it may alter the manufacturer we choose for you or the type of supplies to have available.
Have you ever had a serious reaction after receiving a vaccination? The pharmacist may ask additional questions to determine if you should still receive the vaccine or take extra precautions during administration. Please be prepared to remain in the pharmacy for at least 15 minutes after receiving a vaccination.
Do you have a weakened immune system caused by a medical condition (ex. HIV, cancer, etc.) or do you take immunosuppressive drug therapy?
Do you have a bleeding disorder or are you taking a blood thinner (ex. warfarin, Eliquis, Xarelto, etc.)?
For women: Are you pregnant (or think you may become pregnant) in the next month OR breastfeeding?

For COVID-19 Vaccines Only*

	Yes	No	Unsure
Have you received a dose of COVID-19 vaccine before today?
Have you received another vaccination in the last 14 days?
Have you had a positive test for COVID-19 in the last 90 days?
Have you received monoclonal antibodies or convalescent plasma as treatment for COVID-19 in the last 90 days?

Date of last COVID-19 dose, if known:

Date

Comments to any "yes" answers

Please read the following statement that you must sign before your vaccine is administered.

*Persons who have had a severe reaction to a vaccine or currently have an acute febrile illness should not receive a vaccine. I certify that all information provided on this form is correct. I consent to the staff to administer the vaccination(s) mentioned below to me or the person named above, a minor for whom I represent that I am authorized to sign this Consent Form. I understand that they may be administered all at one time, or on different dates to be determined using clinical judgement for best practices by the pharmacist. I have reviewed the fact sheet(s) that has/have been provided to me concerning the specific manufacturer(s) of the vaccine(s) I am receiving today. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of receiving this vaccine(s) and choose to assume this risk. I fully release and discharge the pharmacist and the pharmacy, its affiliations and their officers and employees from any illness, injury, loss, or damage that may result there from. I acknowledge that I have received a copy of the pharmacy's privacy policies according to HIPAA. I assign payment of authorized insurance benefits due to me to be paid to the pharmacy. I consent to the release of medical information when necessary for billing, reimbursement, and medical protocol. I also allow for the pharmacy to report any vaccinations received to the appropriate state vaccine registry. I am aware that an immunization certified student pharmacist might be administering this vaccine. I agree to wait near the vaccination area for a minimum of 15 minutes or as otherwise instructed by the pharmacist so that I may receive treatment if I begin to feel unwell.

Signature (parent/guardian if patient under 18yo)*

Clear

Print name (parent/guardian if patient under 18yo)*

Date*

Date