COVID Vaccine Consent Form

COVID Vaccine Consent Form - Derby Drug

Once received, the pharmacy will call to schedule your vaccine. The pharmacy may not call until you qualify for the vaccine based on state guidance.
If you have remaining questions, please call us at (316)788-6669.

In order to receive the vaccine, you must be in the most appropriate phase of the vaccine rollout. Visit this link (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations.html) for more information at the federal level.
Section I. Personal Information
Patient's Full Name *

First Name Middle Name Last Name
Mother's Maiden Name *
Date of Birth: *

Month Day Year
Age: *
Phone Number: *
Email: *
Gender: *

Male Female
Ethnicity: *

Hispanic or Latino Non Hispanic/Latino Unknown Prefer not to answer
Race: *

African American American Indian Asian Caucasian Native Hawaiian/Other Pacific Islander Prefer not to answer
Address: *

Street Address Line 2
Primary Care Doctor: *
Doctor City/State: *
Are you one of the following? *

Essential Worker (please bring badge/paystub/other proof of employment) First Responder (please bring badge/paystub/other proof of employment) Healthcare Worker (please bring badge/paystub/other proof of employment) Person with chronic condition (please bring evidence of condition or call ahead to have doctor verify) Resident of a care facility or other group setting Over age 65 No, I am not any of the above (please refrain from scheduling appointment until later phases)
What dose of COVID-19 vaccine will this be? *

First Dose Second Dose
When did you receive your first dose? *

Month Day Year
Date
Section II. Questionnaire for Immunization

Please select the correct option below: *

Yes

Don't know or N/A

COVID-19 Screening Questions:
In the past two weeks, have you tested positive for COVID-19 or are you currently being monitored for COVID-19?

In the past two weeks, have you had a known exposure with anyone who tested positive for COVID-19?

Have you had a new onset of fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, nausea, vomiting, or diarrhea?

Questionnaire for Immunization:
Do you feel sick today?

Do you have an allergy to medications, foods, or any vaccines (eggs, gelatin, thimerosal, neomycin, gentamicin, latex, aluminum, preservatives, baker's yeast, etc.)?

Do you carry an EpiPen?

Have you received COVID-19 monoclonal antibodies or convalescent plasma in the last 90 days?

Have you ever had a serious reaction or fainted after receiving any vaccination?

Have you ever had a seizure, brain disorder, or Guillain-Barre Syndrome?

For women: Are you pregnant or are you planning on becoming pregnant during the next month?

Please specify the allergy from Q2:
Insurance Information
Medicare Information
Commercial Insurance
Uninsured
I authorize the pharmacy to bill my insurance on my behalf for the immunization
If uninsured, you must check the box below to attest that the following information is true and accurate:

I do not have any insurance, including but not limited to Medicare, Medicaid or any other private or government-funded health benefit plan
In order to have your vaccine administration fee paid for by the United States Health Resources & Services Administration's COVID-19 Program for uninsured patients, please select to provide one of the following: *

Social Security Number State identification number and state of issuance Driver's license number and state of issuance
Social Security Number *
State identification number and state of issuance *
Driver's license number and state of issuance *
**Vaccine supply is limited. Please keep your appointment or call if you need to cancel or change it. Additionally, due to vaccine requirements; we may call you to see if you can come earlier, later or to a nearby location. If you miss an appointment, no doses will be held to guarantee your dose.**
Section IV. Signatures

I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (https://www.modernatx.com/covid19vaccine-eua/eua-fact-sheet-recipients.pdf) a copy of which I was provided with this Consent and Release. 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 and Release.
Signature of Person to Receive Vaccine & EUA/VIS (or Signature of Parent/Guardian if Patient is < 18 yo) *

Clear
By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.
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COVID Vaccine Consent Form - Derby Drug