Covid-19 Vaccine Consent Form 2024-2025

Covid-19 Vaccine Administration Record

Professional Pharmacy
9106 Philadelphia Rd # 100
Rosedale,MD 21237-4331

Phone: (410) 687-8113 Fax: (410) 391-3922

Name

First NameLast Name

Schedule your vaccine:

Gender

MaleFemale

Date of Birth

Date

Address

Street Address Line 2

CityState

Zip

Phone

Allergies

Primary Care Physician

Office Fax Number

PCP fax number if available

Mothers Maiden Name

Patient's Email

example@example.com

Race

Ethnicity

Hispanic/LatinoNot Hispanic/LatinoDo not wish to answer

Are you sick today?

YesNo

Have you received a dose of Covid-19 vaccine before today?If yes, choose one below . If not than choose No

Have you ever had a serious reaction after receiving a vaccination or other injection?

YesNo

Please explain if you said yes to question above

Have you ever had a severe allergic reaction to something(i.e a reaction that was treated with Epipen or required you to go the hospital?

YesNo

Please explain if you said yes to question above

Have you received another vaccine in the last 14 days?

YesNo

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?

YesNo

Have you had a positive COVID-19 test within the last 10 days?

YesNo

Have you had monoclonal antibodies or convalescent plasma as treatment for Covid-19 in the last 90 days?

YesNo

Is this a booster dose? If so, do you qualify based on CDC booster requirements? If not sure, ask pharmacist.

YesNo

For women: Are you pregnant or is there a chance you could become pregnant during the next month?

YesNo

Comments to any "Yes" answers

Soc Sec # or MBI:

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.I undersatnd the benefits and risks of receiving this vaccine and choose to assume this risk. I fully 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 paidtothe 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

Signature

Date