COVID19 Vaccine only for Chapman Drug Website

Covid-19 Vaccine Consent Form

If you are already an established customer at Chapman Drug you don't need to fill out this form. Just walkin or make an appointment on our website. If you are a new patient please fill out the form below. You must have insurance (commercial, medicare, medicaid, etc.). Please bring a copy of your insurance card (front and back). You must be 18 years of age or older.
Full Name (First and Last)*

First NameLast Name
Gender at Birth:*
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Primary Phone*
Primary Phone Type*
Cell Phone*
Please enter a valid phone number.
Email*
example@example.com
Primary Care Physician*
Physician's Fax Number
Allergies
Mothers Maiden Name*
Ethnicity:*
Race:*
Screening Questions:
Are you sick today*
Have you recieved a dose of Covid-19 Vaccine Before Today?*
If yes, which one?
Have you ever had a serious reaction after receiving a vaccination or other injection?*
Explain
Have you ever had a severe allergic reaction to something (i.e. a reaction tat was treated with an EpiPen or required you to go to the hospital?*
Explain
Have you received another vaccine in the last 14 days?*
Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem? Have you been diagnosed with rheumatoid arthritis, ankylosing spondylitis, Crohn's Disease, herpes or cold sores?*
Have you had a positive Covid-19 Test within the last 10 days?*
Have you had monoclonal antibodies or convalescent plasma as treatment for Covid-19 in the last 90 days?*
For Women: Are you pregnant or is there a chance you could become pregnant during the next month?
Comments to any "Yes" answers above:
Consent *Persons who have had a severe reaction to a vaccine or currently have an acute febrile illness should not receive a vaccine. I consent to the staff to administer the vaccination(s) mentioned below. I understand that this vaccine has been authorized by the FDA under an Emergency Use Authorization and I have reviewed the fact sheet that has been provided to me concerning the specific manufacturer of the vaccine I am receiving today.l undersatnd the benefits and risks of receiving this vaccine and choose to assume this risk.Ifully release and discharge the pharmacist and pharmacy, its affiliations and their officers and employess from any illness, injury, loss, or damage that may result there from. I acknowledge that I have receievd a copy of the pharmacy's privacy policies according to HIPAA. I assign payment of authorized insurance benefits due to me to be paid tothe pharmacy. I consent to the release of medical information when necessary for billing, remibursement. and medical protocol. I also allow for the pharmacy to report any vaccinations I received to the appropriate state vaccine registry. I am aware that an immunization certified student pharmacist or technician might be administering thevaccine.I agree to wait near the vaccination area for a minimum of 15 minutes or as otherwise instructed by the pharmacist SO that I may receive treatment if I begin to feel unwell
Name (print):*
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Covid-19 Vaccine Consent Form

Screening Questions: