I WANT TO BE PROTECTED FROM THE FOLLOWING (PLEASE CHECK ALL THAT APPLY):

  • Vaccine Consent Form For COVID-19 & Additional Vaccines

  • Format: (000) 000-0000.
  • Date of Birth*
     - -
  • Which vaccine(s) do you wish to receive today?*
  • Are you sick today?*
  • Have you ever received a dose of COVID-19 Vaccine?*
  • 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 and preparations for colonoscopy procedures?*
  • Have you ever had an allergic reaction to Polysorbate, which is found in some vaccines , film-coated tablets and intravenous steroids?*
  • Have you ever had an allergic reaction to a previous dose of COVID-19 vaccine?*
  • Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication? (This would include a severe allergic reaction (e.g. anaphylaxis) that required treatment with epinephrine or EpiPen or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing).*
  • Have you ever had an allergic reaction (e.g., anaphylaxis) to something other than a component of CO?VID-19 vaccine, polysorbate, or any vaccine or injectable medication? This would include food, pet, venom, environmental, or oral medication allergies.*
  • Have you received any vaccine in the last 14 days?*
  • Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19?*
  • Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?*
  • Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?*
  • Do you have a bleeding disorder or are you taking a blood thinner?*
  • Are you pregnant or breastfeeding?*
  • Do you have dermal fillers?*
  • Do you have a history of myocarditis or pericarditis?*
  • Do you have a history of Guillain-Barre Syndrome (GBS)?*
  • Have you been diagnosed with Multisystem Inflammatory Syndrom after a COVID-19 infection?*

  •  

    By signing, I consent to the following:

    • I understand the benefits and risks of the COVID-19 vaccine as described in the Vaccine Information Sheet (VIS), 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 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 hereby give my consent to the pharmacist of Eastridge-Phelps Pharmacy/EP Medical, to administer the vaccine(s) I have requested. I understand the risks and benefits associated with the vaccine(s) being administered and have received, read and/or had explained to me the CDC's Vaccine Information Statement (VIS) on the vaccine(s) I have elected to receive. I have had the opportunity to ask questions that were answered to my satisfaction. As with all medical treatment, there is no guarantee that I will not experience an adverse reaction from the vaccine or medication. I fully release and hold harmless Eastridge-Phelps Pharmacy/EP Medical, its pharmacists and employees from any and all liabilities or claims arising out of, in connection with, or in any way related to the administration of the vaccine(s) given. I understand that the information contained on this form may be shared with the Stated Health Division (SHD) and/or state immunization registries and will remain confidential and will not be released except as permitted or required by law. If eligible, I authorize Eastridge-Phelps Pharmacy/EP Medical to submit a claim for reimbursement on my behalf to Medicare or any other contracted third-party payer. If the claim is denied, I understand that I will be responsible for payment. I acknowledge that I have received a copy of the Eastridge-Phelps Pharmacy Notice of Privacy Practices. Furthermore, I agree to remain near the vaccination location for approximately 15-20 minutes after administration for observation by the administering pharmacist.

  • Date*
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  • Should be Empty: