COVID-19 Vaccine Appointment Scheduling and Consent Form

Please select an appointment*

Vaccine Recipient Name*

FirstNameMiddle NameLastName

Email*

example@example.com

Vaccine Recipient Physical Address*

Street Address

CityState Initials

Zip Code

Date of Birth*

Gender at birth*

Race*

Ethnicity*

Vaccine Recipient Phone Number*

Area CodePhone Number

Mother's Maiden Name*

Required for proper vaccine documentation

Primary Care Provider Name

Primary Care Provider Phone Number

Area CodePhone Number

Emergency Contact Name*

Relationship to Emergency Contact*

Phone Number of Emergency Contact*

Area CodePhone Number

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 30 days? (wait 14 days before getting COVID vaccine)
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? (wait 30-90 days after)
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 Emergency Use Authorization (EUA) Fact Sheet (the Pfizer Fact Sheet is available after clicking submit), 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.
On Behalf of myself, my heirs and personal representatives, I hereby release and hold harmless Avance Care Pharmacy/ InClinic Rx/ Eastern Carolina Medical Center Pharmacy and their staff, associates, successors, affiliates, subsidiaries, officers, directors, contractors, and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the vaccine listed above. I hereby acknowledge that the area where vaccination is administered maybe used to photograph and record video and film footage in connection with the promotional and publicity campaign of this and future vaccination site. By your presence in any of our vaccination facility, you acknowledge that you have read this and have been informed that you may be photographed and recorded as part of the release in video, photography and/or any media now known or hereafter devised, in perpetuity throughout the universe and publicity thereof. If you do not wish to be photographed or recorded please let us know immediately if you see any staff, media, or news channel recording you.

TO READ MORE ABOUT THE VACCINE PLEASE CLICK ON THE VACCINE NAME BELOW -

PFIZER VACCINE INFORMATION

What insurance do you have? If no insurance please select uninsured. *

Please take a Picture of your Insurance Card and Upload *

Browse Files

VACCINE CLINIC LOCATION FOR 9/25/24*

Rows	Please acknowledge
Meredith College, CHESS 137, Health and Human Performance Lab

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

Date Signed

Date

COVID-19 Vaccine Consent Form

Commercial Insurance and Medicaid Accepted