Neptune Clinic 11-8-23 : COVID-19 and Flu Vaccine Form

Clinic Organized by:

Neptune Senior Center

&

Marlboro Medical Arts Pharmacy

479 County Highway 520, Suite A-102, Marlboro, NJ 07746

Phone: 732-946-1600; Website: www.marlbororxnj.com

Clinic Location:

1607 Corlies Ave, Neptune, NJ 07753

Date : 11/08/2023 ; Time: 2pm to 6pm

Neptune Vaccine Clinic

COVID-19 and Flu Vaccine Form.

Please fill out the form below, sign & submit to secure your appointment.

SELECT CLINIC DATE

Vaccine Clinic Site

Name*

First NameLast Name

Date of Birth*

Date

Gender*

MaleFemale

Ethnicity

Address*

Address

Street Address Line 2

CityState

Zip

Phone*

Email*

example@example.com

Do you have insurance?*

YesNo

If you are uninsured, please go to covidaccess.com and register to receive a voucher.

When you register, please select Marlboro Medical Arts Pharmacy as your provider. You will need to add zip code 07746 to locate the pharmacy.
Once you are successfully registered, you will be able to either download or print a vaccine voucher, which you must provide to receive a free covid vaccine.

Please upload front of the insurance card (USE WHITE BACKGROUND)

Please upload back of the insurance card (USE WHITE BACKGROUND)

If you are unable to upload photo of your insurance card, please add details in the box below and bring your insurance card(s) with you at the time of your appointment (Please include name of your insurance, ID number, and Group Number below; add as much details as possible)

Please upload front of your Driver's License - Identification (ID) card*

Have you had Any Vaccine(s) in the past 4 weeks? If Yes, what was given and when:

Would you like to get a Covid-19 vaccine as well as a Flu shot TODAY (or on the clinic day)?

Select the LAST COVID Vaccine or Booster your received from the list below.*

Enter the date you received your last COVID Vaccine or Booster

Date

IMPORTANT: Select the COVID Vaccine/Booster you would like to receive TODAY (or on the Clinic Day)*

Are you over 65 years of age?

High Dose Flu Shot is recommended for age over 65, please select Flu vaccine from list below

Please answer the following questions:

Are you sick today? (For example: a cold, fever, acute illness) (Leave blank if filing this form in advance for a clinic)

YesNo

Do you have allergies to medications, food, or any vaccine? (For example eggs, gelatin, neomycin, Thimerosal, latex, etc Please list*

Yes, please list in the other section belowNoOther

Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g., diabetes), anemia, or other blood disorder?*

Yes, please list in the other section belowNoOther

Do you have cancer, leukemia, AIDS, or any other immune system problem?*

Yes, please list in the other section belowNoDon't knowOther

For women: Are you pregnant or is there a chance you could become pregnant during the next month?

YesNo

Have you ever had a reaction after receiving a vaccine, including feeling faint or dizzy?*

YesNo

Please read ALL of the following statements, if consent is given, please sign and date below.

I have been provided with the Vaccine Information Sheet (VIS) and/or been provided with information regarding to the vaccine I am receiving.
I understand all the benefits and risks of the vaccine and have had the chance to ask questions regarding it. I voluntarily assume full responsibility for any reactions that may result.
I request the vaccine be given to me and authorize and direct this health care provider to use or disclose my health information during the term of this Authorization to the physician responsible for this protocol of specific health information of people vaccinated by this provider (standing order practitioner), my Primary Care Physician (PCP), my insurance plan and/or state federal registries, where required for purposes of treatment, payment or other health care operations. This only allows this provider to disclose the following medical records: only documents related to the vaccination received today. This authorization will remain in effect until my health care provider discloses my health information to the recipient identified above; my health care provider cannot guarantee that the recipient will not disclose my health information to a third party. The third party may not be required to abide by this Authorization or applicable federal and state law governing the use and disclosure of my health information. I understand that I may refuse or revoke this Authorization at any time. I understand that this authorization will remain in effect until the term of this authorization expires or I provide a written notice of revocation to my health care provider. The revocation will be effective immediately upon my health care provider's receipt of my written notice.

HIPAA Privacy Information and Medical Records

I have acknowledged that I have received the provider's Inc Notice of Privacy Practices which may be provided at my request.
For Medicare, Medicaid, or Insurance Billing: I authorize this provider to release information and request payment. I understand that the information given by me in applying for payment is correct.
I authorize the release of all records to act on this request and I request that payment of benefits be made on my behalf.

Signature of patient or guardian (Please sign your name CLEARLY)*

Date*

Date

Screening Questions and Consent: