NYS Emergency Order Spikevax (Standard dose) COVID-19 2025-2026 Consent and Questionnaire

Crestwood Pharmacy 26A Picotte Drive Albany, NY 12208 (518) 435 - 2315

Please Read the following Vaccine Information Sheet (VIS)

Spikevax (standard dose) COVID-19 Vaccine Administration Form

This form is for the New York State emergency order released 09/05/2025 for those under 65 years old who are not immunocomprosied under Dr. James Mcdonald's standing order.

Date*

Date

First Name*

MI

Last Name*

Date of Birth*

Date

Age*

Gender M/F*

Race*

Ethnicity*

Phone*

Home address*

City*

State*

Zip*

Insurance Plan Name*

ID or Last 4 digits of SSN if you have Meidcare*

BIN

PCN

RX Group

Primary Care ProviderDoctor Name

Provider's Phone

Please answer the following questions. They will help us determine your eligibility to receive a vaccination

Do you currently feel sick?*

YesNoUnsure

Have you been sick in the last 2 weeks?*

YesNoUnsure

Do you currently have a fever?*

YesNoUnsure

Do you have any health conditions (e.g. diabetes, heart disease, asthma, etc.)?*

YesNoUnsure

If yes please list (N/A for none)*

Have you received theCOVID-19 vaccine before?*

YesNoUnsure

Have you had a reaction to the vaccine before?*

YesNoUnsure

If yes what was the reaction (N/A for none)*

Was your last COVID-19vaccine is received more than 6 months a go?*

YesNoUnsure

Are you over 65 years old?*

YesNoUnsure

Are you under 65 years old and immunocompromised*

YesNoUnsure

If yes please list your conditions (n/a if none)*

Are you allergic to thimerosal?*

YesNoUnsure

Are you currently pregnant?*

YesNoUnsure

Are you a healthcare worker?*

YesNoUnsure

Have you ever had Guillain-Barre Syndrome?*

YesNoUnsure

Do you have a blood clotting disorder?*

YesNoUnsure

I, the undersigned, have read or had explained to me the vaccine information sheet (VIS I understand that it is not possible to predict all side effects or complications associated with receiving vaccination I understand the risks and benefits associated with the influenza vaccine and have had any questions satisfactorily answered. I voluntarily request that the vaccine be given to me or for the aforementioned person for whom I am authorized to make this request.I understand that my vaccination will be submitted NYSIIS (New York State Immunization Information System) unless otherwise stated.

I acknowledge that all of the information entered above is accurate to my knowledge.

Signature*

Print Name*

Date*

Date

Appointment