Clone of BioNTech Vaccine Consent

Vaccine Consent Form
This clinic is for Flu Vaccine (anyone 9 years old and up) and Moderna Covid Vaccine (anyone 12 years old and up)
Which vaccine do you want to get?*

FluCovid
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Sex*

MaleFemale
Age*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Race

American Indian or Alaska NativeAsianNative Hawaiian or other Pacific IslanderBlack or African AmericanWhiteOtherUnknown
Ethnicity

Hispanic or LatinoNot Hispanic or LatinoUnknown
Primary Care Physician Name*

First NameLast Name
Primary Care Physician Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
The following questions will help us determine your eligibility to be vaccinated today (please ask for assistance if needed):
Do you feel sick today?*

YesNo
Have you been diagnosed with or tested positive for COVID in the last 14 days?*

YesNo
Have you been vaccinated in the past 28 days?*

YesNo
Please list vaccines:*
Do you have any health conditions, such as: Heart Disease, Diabetes, Cancer, or Asthma?*

YesNo
Please list health conditions:*
Do you have ALLERGIES to medications, latex, food, or vaccines? Examples: Egg protein, Cow protein, Gelatin, Gentamicin, Polymyxin, Neomycin, Phenol, Yeast, or Thimerosal.*

YesNo
Please list allergies:*
Have you ever had a serious reaction after receiving an immunization, including fainting, or feeling dizzy? Did you require medical assistance?*

YesNo
Have you ever had a seizure disorder for which you are taking seizure medication(s), a brain disorder,Guillain-Barre Syndrome (a condition that causes paralysis), or other nervous system disorders?*

YesNo
Are you on, or have you recently taken medications that affect your immune system? Examples: corticosteroids (Prednisone), anti-rejection medications, chemotherapy*

YesNo
When was your last dose and what was your last dose (in milligrams)?*
Are you pregnant, considering becoming pregnant in the next month, or breastfeeding?*

YesNo
Have you been treated with antibody therapy specifically for COVID-19(Monoclonal antibodies or convalescent plasma)?*

YesNo
Was your child vaccinated with the seasonal influenza vaccine after July 1, 2024?*

YesNo
I GIVE CONSENT for my child named at the top of this form to be vaccinated with this vaccine. (If this consent form
is not signed, then you child will not be vaccinated)
Signature
If you are uploading an image of your insurance card(s), you do not have to fill in the specifics in the spaces provided.

Thank you

Pharmacy Card

Rows	Information
RxBIN
RxPCN
RxGroup/RxGRP
Member ID

Scan of Pharmacy Insurance Card

Cancelof

Medicare Part B

Rows	Information
Medicare Number *number on red/white/blue card
Last 4 digits of SSN

Do you have Medicare Advantage (Part-C)?*

YesNo
Scan of any Medicare Insurance Cards

Cancelof
Appointment*
CONSENT FOR SERVICES: I have been offered with the Vaccine Information Sheet(s) or patient fact sheet corresponding to the vaccine(s) that I am receiving. I have read the information provided about the vaccine I am to receive. I have had the chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of vaccination and I have voluntarily assumed full responsibility for any reactions that may result. I understand that I should remain in the vaccine administration area for a minimum of 15 minutes after the vaccination to be monitored for any potential adverse reactions. I understand if I experience side effects that I should do the following: call the pharmacy, contact my doctor, and/or call 911. I request that the vaccine be given to me or to the person named above for whom I am authorized to make this request.

AUTHORIZATION TO REQUEST PAYMENT: I do hereby authorize The Pharmacy to release information and request payment. I certify that the information given by me in applying for payment under Medicare or Medicaid or Private Insurance is correct. I authorize benefits be made on my behalf.

DISCLOSURE OF RECORDS: I understand that The Pharmacy may be required to or
may voluntarily disclose my health information to the physician responsible for this protocol of specific health information of people vaccinated at The Pharmacy or at Clinics (if applicable), and/or my Primary Care Physician (if I have one), and/or my insurance plan, and/or health systems and hospitals, and/or state or federal registries such as Massachusetts Vaccine Registry (MIIS), for purposes of treatment, payment,
or other health care operations (such as administration or quality assurance). I also understand that The Pharmacy will use and disclose my health information as set forth in the Notice of Privacy Practices (copy is available in-store, on-line or by requesting a paper copy from the pharmacy).

AUTHORIZATION: I do hereby consent the Pharmacy to submit vaccination data to state and federal vaccination registries.
Signature*
Date*

MonthDayYear
Date
Should be Empty:

Vaccine Consent Form