PARKING LOT CLINIC FLU/COVID 2026

FLU / COVID Vaccine Consent Form

***PARKING LOT FLU AND COVID SHOTS***
September 28- October 2nd
View other available dates (non-parking lot): CLICK HERE
Section 1: Vaccine Recipient Information
I have receive the Flu and / or COVID shot last year at Scott Pharmacy and my insurance information has not changed.
Name:
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Gender
Age
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address:

Street Address (NO PO BOXES)

Street Address Line 2

CityState

Zip Code
Email
example@example.com
Primary Healthcare Provider:
2026–2027 COVID-19 Vaccine
The 2026–2027 COVID-19 vaccine is expected to be available this fall, with an updated formula designed to better match currently circulating COVID-19 variants.

Vaccination may be based on an individual/shared clinical decision with a healthcare provider, depending on current CDC recommendations and the specific vaccine's FDA-approved indication.

Vaccine availability, eligibility, recommendations, and insurance coverage are subject to change.
Please select requested shot(s):
Section 2: Pre Vaccination Assessment:

The following questions will help us determine if there is any reason you should not get a vaccine today. If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions may be asked. If a question is not clear, please ask your healthcare provider to explain.

Please answer the following:

Rows	Yes	No	Don't know
1. Are you feeling sick today?
2. Have you ever had a severe allergic reaction (e.g. anaphylaxis) to something? For example, a reaction for which you were treated with epinephrine or EpiPen, or for which you had to go to the hospital?
3. Do you have allergies to a vaccine component, thimerosal, neomycin, or latex?
4. Do you have an egg allergy?
5. Do you have a weakened immune system caused by something, such as HIV infection or cancer, or do you take immunosuppressive drugs or therapies?
6. Have you ever had Guillain-Barre syndrome?
7. Are you pregnant or breastfeeding?
8. For COVID: Have you received passive antibody therapy (monoclonal antibodies) as a treatment for COVID.
9. For COVID: Have you had a COVID Vaccine in the last 6 months.
10. For COVID: Have you tested positive for COVID in the last 90 days. If yes, you may have a better immune response if you wait 90 days from your positive date, but you still may receive it sooner based on personal risk of severe COVID and local levels of COVID.

PARKING LOT EVENT SIGNUP: SEPT 28 - OCT 02. Please pick an appointment slot :
Prescription insurance OR please bring your insurance card with you!:
ID #: RX BIN:
RX GROUP (GRP): RX PCN:
For Medication patients, please type in your Medicare Part B (Red/White/Blue Card) ID #:
Section 3: Consent

I have read or have had explained to me the information provided in the Vaccine Information Statement (FLU VIS) and (COVID VIS). I have had a chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of FLU / COVID vaccine and ask that the vaccine be administered to me or the person named above for whom I am authorized to make this request.
Signature:
Should be Empty:

FLU / COVID Vaccine Consent Form