In_House_Booster

  • COVID-19 Vaccine Consent

    Please have your pharmacy insurance card ready when completing. If you are having difficulty completing this form, feel free to call us at 804-733-7711.

  • *Pharmacy Use Only*      Temperature: __________      COVID Symptoms: Y or N

  • Date
     - -
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • What dose are you looking to receive?*
  • I have received a Pfizer or Moderna 2nd dose, OR Johnson & Johnson primary dose, OR, booster at minimum 2 MONTHS AGO*

  • You may not yet be eligible to receive the booster.

    Contact Walnut Hill Pharmacy at 804-733-7711 to determine your eligibility.

  • Date of last vaccination *

  • I request the following first/second dose:*
  • I request the following booster dose*
  • Would you like to receive a flu shot during this appointment as well?
  • Schedule Your Appointment*
  • Schedule Your Appointment*

  • Payment

    Vaccines may be billed to your pharmacy benefits. Please contact your plan directly if you have questions regarding insurance coverage of vaccines.
  • Choose a payment method*
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  • Insurance Card Information

    Please input each of the following for your insurance card. *NOTE* If you are a current patient of ours, we will have your insurance information on file, and this section is not necessary. Please bring this information with you to your appointment.
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  • Have you ever had a severe allergic reaction (e.g. anaphylaxis) to something? For example, a reaction you were treated with epinephrine or an Epipen, or for which you went to the hospital?*
  • Was the severe reaction after receiving another vaccine or injectable medication?*

  • If the answer to question 6 is Yes, Please provide the treatment date:

  • Have you ever had an allergic reaction to a component of the COVID-19 vaccine, including polyethylene glycol (PEG) or Polysorbate which is found in some medications, such as laxatives and preparations for colonoscopy procedures?*

  • PLEASE CONTACT PHARMACY AS THIS IS A POSSIBLE CONTRAINDICATION TO COVID-19 VACCINES

  • Consent to Vaccination

    I have read, or have had read to me, the written information regarding the vaccine(s) being administered. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s) being administered and have received a copy of a current Vaccine Information Sheet. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Walnut Hill Pharmacy, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s). I certify that I am at least 18 years old and hereby give my consent to the pharmacists of this Pharmacy to administer the vaccine(s). If under 18 years old signature by parent or guardian is required. I agree to wait near the vaccination location for approximately 15 minutes for observation by the pharmacist.

  • The products and/or services provided to you by Walnut Hill Pharmacy are subject to the supplier standards contained in the Federal Regulations shown at 42 Code Of Federal Regulations Section 424.57(c ). These standards concern business professional and operational matters(e.g. honoring warranties and hours of operation). The full text of these standards can be obtained at http://ccfr.gpoacccss.gov. Upon request we will furnish you a written copy of the standards.
    By signing this form I consent that I have received the HIPAA Privacy Practices and completed this form completely and to the best ofmy knowledge.

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  • FOR PHARMACY USE ONLY

     

    Vaccine/Manufacturer: COVID-19/Pfizer or Moderna Route and Dose: IM 0.5ML or 0.3ML or 0.25ML

    Date Given _______     Site Given:   LD     RD     RPH Initials _______     

    • Lot/Expiration _______    Comments _______________     Fact Sheet Date: 09/23
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