Clone of Vaccine Consent Form WPU 10/08/2025

If you have remaining questions, please call us at (919)832-4641

Section I. Personal Information

First Name

Last Name

Address (Home address not school)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth

Date

Gender:

Race:

Ethnicity:

Phone Number:

Email:

Please select which vaccination you are requesting

The CDC recommends COVID-19 vaccination for people age 6 months and older based on individual-based (shared clinical) decision-making. For people ages 6 months-64 years, the potential benefit of vaccination is greatest for those who have factors that increase their risk for severe COVID-19 infection. These conditions are listed below. After reviewing, please indicate below if you wish to receive the COVID-19 vaccination today.

• Asthma
• Cancer
• Cerebrovascular disease
• Chronic kidney disease
• Chronic lung diseases, limited to bronchiectasis, COPD (Chronic Obstructive
Pulmonary Disease), interstitial lung disease, pulmonary embolism, pulmonary
hypertension
• Chronic liver diseases, limited to cirrhosis, non-alcoholic fatty liver disease, alcoholic
liver disease, autoimmune hepatitis
• Cystic fibrosis
• Diabetes mellitus, type 1 and type 2
• Disabilities, including Down syndrome (complete list included here)
• Epilepsy
• Heart conditions (such as heart failure, coronary artery disease, or cardiomyopathies)
• HIV (human immunodeficiency virus)
• Mental health conditions, limited to mood disorders (including depression),
schizophrenia spectrum disorders
• Neurologic conditions, limited to dementia and Parkinson’s Disease
• Overweight (BMI >25 kg/m2)
• Physical inactivity
• Pregnancy or recent pregnancy
• Primary immunodeficiencies
• Sickle cell disease
• Smoking, current or former
• Solid organ or blood stem cell transplantation
• Substance use disorders
• Tuberculosis
• Use of corticosteroids or other immunosuppressive medications

Type a question

Current regulations require you to agree to a shared clinical decision to receive the COVID-19 vaccination. By checking "No" you have indicated that you do not wish to have this vaccination. Should you want to discuss further, please call the pharmacy or see a health-care provider during the vaccination clinic.

Pick your time

Please fill out the information below using your current insurance card. The insurance card must have pharmacy specific information in order for us to bill for the vaccine.

We have attached an example here to guide you. If your insurance card does not have this information, it is not your prescription insurance card. If you have questions or concerns please reach out to us directly at 919-832-4641

Insurance ID

RX BIN

RX PCN

RX Group(GRP) - if no group is listed on the card enter a "NA" here

Section IV. Signatures

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 influenza Vaccine Information Sheet and a current COVID-19 Vaccine information sheet. I certify that I am at least 18 years old and hereby give my consent to the pharmacists of this Mutual Member Drug Store to administer the vaccine(s). If under 18 years old signature by parent or guardian is required. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Mutual Drug, 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).

Signature of Person to Receive Vaccine EUA/VIS (or Signature of Parent/Guardian if Patient is < 18 yo)

I have received a copy of the notice of Privacy Practices. I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.

Signature of Acknowledgment of Notice of Privacy Practices:

Do you have insurance?

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.

Vaccination Consent Form - WPU

Insurance information