Updated Chapman Drug COVID-19 Vaccine Appointment Scheduling and Consent Form

COVID-19 Vaccine Consent Form
Spikevax, the NEW Moderna Covid Booster has arrived. We are receiving a limited supply at this time. At this time the COVID Vaccine is by appointment only. You must have insurance (commercial, medicare, medicaid, etc.), it is no longer "free" if you don't have coverage. Please do not make an appointment if you do not have coverage. At this time you must be 18 years of age or older.
Select an appointment time*
Vaccine Recipient Name*

FirstNameMiddleInitialLastName
Vaccine Recipient Physical Address*

Street Address

Street Address Line 2

CityState Code

Zip CodeCountry
Date of Birth*

MonthDayYear
Gender at birth*
Race*
Ethnicity*
Vaccine Recipient Primary Phone Number*
Format: (000) 000-0000.
Primary Phone Type*
Vaccine Recipient Cell Phone Number*
Format: (000) 000-0000.
Mother's Maiden Name*
Required for proper vaccine documentation
Primary Care Provider Name
Emergency Contact Name*
Relationship to Emergency Contact*
Phone Number of Emergency Contact*
Format: (000) 000-0000.

COVID-19 Vaccine Screen Questions*

Rows	Yes	No
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 acomponent 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 14 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?
8. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? [note: monoclonal antibodies does not include antibiotics that you would be prescribed and filled at a pharmacy]
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?

Consent (check each box below after reading and prior to signing the form)*

Rows	Check each box
I understand the benefits and risks of the COVID-19 vaccine as described in the Fact sheet, 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.

The vaccine is no longer necessarily available for free but is usually covered by insurance. Please check only one of the following.*

Rows	Check one
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 and I will be charged for the vaccination.

Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):
Date Signed

MonthDayYear
Date
Email*
example@example.com
After completing form you should get a confirmation email for "Jotform.com".
Should be Empty:

COVID-19 Vaccine Consent Form

After completing form you should get a confirmation email for "Jotform.com".