Claremont Colleges Vaccine Consent

This registration is for the 2023-24 COVID-19 and/or Flu vaccine.

We have Pfizer (Comirnaty) and Moderna (Spikevax) for ages 12 and up.

The vaccine is no longer provided by the government and may have a charge, depending on your insurance coverage. We are not able to bill Kaiser, or some out of state or closed network plans.

The CDC has vaccine recommendations available at https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/covid-19.html. Vaccine information and disclosures are also available at www.hendrickspharmacy.com/covid19.

Which COVID-19 vaccine would you like to receive at this appointment?*

Which other vaccine would you like at this appointment?

Vaccine Recipient Date of Birth*

Age

A parent or guardian must be present during the vaccine appointment for any patient under age 18.

	Check box
Check this box to indicate that a parent or guardian will be present during the entire vaccine appointment and will sign the consent form.

Any COVID-19 Previous Dose?*

	Yes	No
Have you ever received a dose of ANY COVID-19 Vaccine?

The 3rd Dose (also known as an Additional Dose) is currently only available for people who have a moderately to severely weakened immune system and have received the first 2 doses (or single dose for Janssen) at least 28 days prior.

	Check box
Check this box to indicate that you meet the criteria outlined by the CDC to be eligible to receive the Additional Dose. You will be required to sign an attestation upon arrival before receiving the Additional Dose.

The First Booster Dose has been approved for individuals ages 5 to 11 after 5 months of completing the primary series of the Pfizer vaccine. You must bring your vaccine card or valid proof of previous doses to your appointment.

	Check box
Check this box to indicate that you are age 5 to 11 and have completed the primary series of Pfizer at least 5 months prior and you will bring VALID proof of previous vaccine doses to the appointment.

The Bivalent Booster Dose has been approved for individuals age 6 months and over. You must bring your vaccine card or valid proof of previous dose(s) to your appointment.

	Check box
Check this box to indicate that you are 6 months or over and you will bring VALID proof of previous dose(s) to the appointment.

COVID-19 Vaccine Manufacturer for the previous dose received

Date of last dose of COVID-19 Vaccine that you received

Date

Sorry, you must be at least 12 years of age to receive the Pfizer (Age 12+), Moderna (Age 12+), or the Novavax Vaccine.

You must be at least 5 years of age and less than 12 to receive the Pfizer (Age 5-11) Vaccine.

Please change your selection or correct your birth date.

Sorry, we are only able to bill vaccine to Medi-Cal for adults age 19 and older. You will need to find a provider enrolled in the Vaccine For Children (VFC) Program.

Sorry, RSV is only indicated for age 60 and over.

Sorry, High Dose Flu is only indicated for age 65 and over.

Weakened Immune System?*

	Yes	No
Do you have a moderately to severely weakened immune system caused by something such as an HIV infection or active cancer treatment or do you take immunosuppressive drugs or therapies?

Please select the time you plan to arrive.*

Vaccine Recipient Name*

First NameMiddle NameLast Name

Gender at birth*

Vaccine Recipient Physical Address*

Street Address

Street Address Line 2

CityState Initials

Postal / Zip Code

Email (to receive notification of appointment and informational documents)

example@example.com

AGE

Race*

Required by California Department of Public Health

Ethnicity*

Required by California Department of Public Health

Vaccine Recipient Phone Number*

A Cell Phone is preferred to obtain access to the California Digital Record

Mother's First Name*

Required for proper vaccine documentation

Primary Care Provider Name (optional)

If you would like to have a copy of this record sent to your Primary Care Provider, please provide the name here and inform the staff at check-in.

Emergency Contact Name*

Relationship to Emergency Contact*

Phone Number of Emergency Contact*

Sorry, the Bivalent Booster Dose has only been approved for ages 5 and up for Pfizer or ages 6 and up for Moderna.

Please check the Birth Date entered or select a different dose.

Novavax does not have a Bivalent Booster.

Please select a different brand or a different dose.

Sorry, the Additional Dose (immunocompromised person) is for individuals who are moderately to severly immunocompromised.

Visit the CDC website for details regarding who is considered moderately to severely immunocompromised.

Please review your selections and make the necessary correction(s).

If you have further questions, please contact the pharmacy.

Previous COVID-19 vaccine dose

	Yes	No
Have you ever had an allergic reaction to a previous dose of COVID-19 Vaccine?

COVID-19 Vaccine Screening Questions (If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just means additional information may be necessary before vaccination.)*

	Yes	No
1. Have you ever had an allergic reaction to any component of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures, or Polysorbate?
2. Have you received hematopoietic cell transplant (HCT) or CAR-T-cell therapies since receiving the COVID-19 Vaccine?
3. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?
4. 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 (including Eggs), pet, environmental, or oral medication allergies.
5. Have you ever had COVID-19 AND was treated with monoclonal antibodies or convalescent serum or was diagnosed with Multisystem Inflammatory Syndrome (MIS-C or MIS-A)? [note: monoclonal antibodies does not include antibiotics that you would be prescribed and filled at a pharmacy]
6. Do you have a history of myocarditis or pericarditis?
7. Do you have a history of thrombosis with thrombocytopenia (TTS) following an adenovirus-vectored vaccine (e.g. Johnson & Johnson, AstraZeneca, or Sputnik COVID-19 vaccines)?
8. Do you have a bleeding disorder or a history of heparin-induced thrombocytopenia (HIT) or are you taking a blood thinner?
9. Are you pregnant or breastfeeding?
10. Have you received dermal fillers?
11. Have you had Guillain-Barre Syndrome, a condition that causes paralysis?

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

	Check each box
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet or Vaccine Information Statement (VIS), a copy of which I was provided with this Consent Form (also available online at http://www.hendrickspharmacy.com/covid19). I have had a chance to ask questions that were answered to my satisfaction. I am eligible to receive the vaccine at this time according to the current guidelines and 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 acknowledge that my immunization information from this visit will be sent to the California Immunization Registry and may be shared with other providers unless I choose to opt out.
I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Hendricks Pharmacy, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s).
I have read and reviewed the Notice of Privacy Practices available at www.HendricksPharmacy.com.
I understand that I may be responsible for the cost of the vaccine and its administration should my insurance not cover it.

Insurance (We are not able to bill Kaiser or some out of state or closed network plans)*

	Yes	No
Do you have health or medical insurance (examples include Medicare, Medi-Cal, or private health policies)? We are not able to bill Kaiser or some out of state or closed network plans. You are welcome to pay out of pocket for the vaccine if your insurance will not cover the cost.

Type of insurance

Please select the type of prescription insurance that you have. (We can't bill Kaiser or some out of state or closed network plans.)

Sorry, we can't bill Kaiser insurance. If you would like to get a vaccine and pay out of pocket, please change your response to no insurance and submit.

Insurance ID#

Please enter the ID# from your insurance card (Medicare, Medi-Cal, or Private/Other).

Since you indicated you have insurance, please read and check this box.

	Check box
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 may be responsible for the cost, or a portion of the cost, of the vaccine and its administration should your insurance not fully cover it.

Check box

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 may be responsible for the cost, or a portion of the cost, of the vaccine and its administration should your insurance not fully cover it.

Since you indicated you do not have insurance, please read and check this box.

	Check box
I do not have any insurance or I not not wish to have the pharmacy bill my insurance, including but not limited to, Medicare, Medicaid, or any other private or government-funded benefit plan and I understand that I will have to pay at the pharmacy for the vaccine prior to administration.

For uninsured patients, please select at least one of the following that you will bring with you to your appointment.

Social Security NumberState identification number and state of issuanceDriver's license number and state of issuance

ID #

Please enter your State ID/Driver's License #

Full Name

Date/Time

DoseDate

Date

Hour MinutesAM/PM Option

NextDoseText

Time

Hour Minutes

AM/PM Option

CurrentDate

Date

Claremont Colleges Vaccine Consent Form