2024 COVID-19 Vaccine Consent Form

COVID-19 2024/25 BOOSTER Vaccine Consent Form

MODERNA'S "SPIKEVAX" FOR 12 YEARS AND OLDER IS ONLY BOOSTER AVAILABLE CURRENTLY
Appointment*
The COVID-19 vaccine will reduce the risk of being suffering from the new type of Coronavirus disease as known as COVID-19.

Please be aware that the vaccine is not completely effective like all other medicines. It can take a few weeks for your body to build up protection from the vaccine. There is always a chance to get infected by Coronavirus even with the vaccine; however, the vaccine lessens the severity of any infection.

You still need to follow the health instructions in your workplace and in public areas, such as wearing a mask and keeping the distance from others after you received the COVID-19 vaccine.

The vaccine has some side effects as the other vaccines/medicines, but not everyone gets them.

The most likely side effects that you may experience from the vaccine
- Fever
- Pain at the injection site
- Redness and hardness of the skin at the injection site
- Headache
- Muscle aches or pain
- Joint aches or pain
- Fatigue (tiredness)
- Nausea/vomiting
- Chills
- Underarm gland swelling on the side of study vaccination
If you think you are experiencing any side effects, please remain calm and see your doctor immediately.

If you are currently pregnant or planning to get pregnant or your partner is planning to get pregnant; please see your doctor before getting vaccinated.

Select the most appropriate response:*

	Yes	No	Don't know
Do you have allergies to latex, food, medications, or vaccine components? (such as eggs, thimerosal, gelatin, neomycin, phenol, or bovine protein)?
Did you ever experience any serious reaction after getting a vaccine?
In the past year, did you receive a transfusion of blood or blood products, or get injected immune (gamma) globulin or any antiviral drug?
Did you have any brain or other nervous system problems?
Have you gotten vaccinated in the last 4 weeks?
Are your pregnant or planning to get pregnant or your partner is planning to get pregnant?

Do you have any of the followings? (select all that apply)

Lung diseaseHeart diseaseAsthmaKidney DiseaseDiabetesAnemiaBlood disorderNone
Do you have immunocompromised condition? (select all that apply)

CancerLeukemiaLymphomaHIV/AIDSTransplantAspleniaCSF leakCochlear implantNone
Have you ever tested positive for COVID-19?

YesNo
Test Date

MonthDayYear
Date
In the last 14 days, have you contacted with a person who was confirmed to have COVID-19?

YesNoNot sure
In the last 14 days, have you travelled internationally?

YesNo
Do you have any of the followings?

CoughColdFeverShortness of breathSore throatLoss of smell/tasteAbdominal pain/diarrheaAbnormal bruising or bleeding/eye redness
Personal Information,

First NameLast Name
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relation
Phone Number

Area CodePhone Number
Insurance information, Type of Insurance?*

Private/CommercialMedicare MUST PROVIDE MEDICARE NUMBERMedicaidNo insurance, Must go to www.covidaccess.com and obtain "voucher certificate", come back and enter info in fields provided.
Prescription Insurance Info (RX BIN NUMBER)
Prescription Insurance info (BIN NUMBER)
Prescription Insurance info (PCN NUMBER)
Prescription Insurance info (Card Holder ID Number)
Prescription Insurance info (Rx Group Number)
Relationship to Cardholder
FOR MEDICARE PATIENTS ONLY (MEDICARE NUMBER) can be found on the red/white/blue card:
By signing this form,

I hereby accept that I have read and understood the acknowledgment letter provided above.

I declare that the information I have provided above is correct.

I am giving my full consent to get the COVID-19 vaccine of my own will.

I certify my receipt of the services covered by this claim. I request that payment be made on my behalf. I authorize the holder to release medical information about me to any party involved in payment or their agents.

I have read, or have had read to me the Vaccination Information Sheet (VIS) or Emergency Use Authorization (EUA) regarding the vaccine(s). I have had the opportunity to ask questions that were answered to my satisfaction and
understand the benefits and risks of the vaccine(s). I consent to, or give consent for, the administration of the vaccine(s). I fully release and discharge Rite Aid Corporation, its affiliates/subsidiaries, officers, directors, and employees from any liability for illness, injury, loss, or damage which may result there from.
Date*

MonthDayYear
Date
Signature*

Clear
PHARMACY USE ONLY

Do Not Fill out anything past this section please
VACCINE GIVEN AND MANUFACTURER

COVID-19 SPIKEVAX (MODERNA)
ROUTE

IM LEFT ARMIM RIGHT ARM
DATE ADMINISTERED
LOT NUMBER AND EXPIRATION
Name of Vaccine administrator:
PHARMACIST SIGNATURE AND DATE:
Should be Empty:

COVID-19 2024/25 BOOSTER Vaccine Consent Form

PHARMACY USE ONLY