LSP COVID Vaccine Consent Form Logo

  • COVID-19 Vaccine Consent Form

    * Please fill out the required details below
  • Link to FACTS ABOUT CcOvId

  • If you have remaining questions, call us at (412)-344-6700

    Please note: only one (1) patient per form

     

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    Please fill out this form as thoroughly as possible.

  • Patients: Start form here!

  • Section I. Personal Information


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    What is your name?         

    What is your relationship to the minor?      
         


    Please fill out the remainder of the form (including when booking your appointment) with the patient's (your child's) information.


    Children age 16 and older may attend their appointment without a parent or guardian, as this form acts as parental consent.
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  • Coverage Information

  • Insured Patients: 

  • Medicare Patients (age 65+)

    Please upload a picture of your newest Medicare Card (Red White & Blue Card) and input your medicare number (no dashes) below. 

    Medicare requires your Medicare number to be used to document the vaccine administration under Medicare Part B.

    We ask that you bring your Medicare card and your prescription insurance with you to your appointment. 

    If you do not have your newest Medicare card or number, please call 

    1-800-MEDICARE (1-800-633-4227)

    then input your number below and fill out any other relevant information.

    This cannot be done at the pharmacy by staff due to Medicare privacy regulations.

    Please keep your number safe and bring it with you to your appointment.

    Your newest number is a random mix of numbers and letters; this number does not contain your social security number. 

     

     

    Additionally, if you have a prescription insurance or Medicare Advantage plan, please bring your card with you to your appointment. The pharmacy is not told by the insurance carrier or Medicare prior to vaccination which plan will be needed and requirements have changed.

     

  • Medicaid Patients

    Please upload a picture of your newest Medicaid Card and/or input your Medicaid number below.

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  • AND/OR complete the following:
    Insurance Provider*:  
    Member ID*:    
    BIN:
    PCN:      
    RxGrp*:         

    Cardholder* -- Vaccine recipient is the:  
              

  • *Please note: your card may not contain all of the above information. If you card does not have any of the above (except insurance provider), please leave that area blank

  • Medicaid Info:

    Medicaid ID/Recip #:      
    Card Issue #:      

  • Uninsured Patients:

  • Information and Consent

    • Terms and Conditions 

    • Please Read Carefully

      Terms and Conditions:

      I agree to follow the policies set forth by Lebanon Shops Pharmacy and the vaccination team to protect myself, the staff, and other patients present in the pharmacy, which includes:

      • Arriving on time to my appointment, as any patient not on time risks being required to reschedule to maintain social distancing
      • Bringing my current ID to the appointment
      • Bringing my insurance card or Medicare/Medicaid card to the appointment (if applicable)
      • Participation in symptom screening, including a COVID-19 symptom questionnaire and a temperature check, if requested by pharmacy staff
      • Answering or filling out any additional screening questionnaires as required by law or the pharmacy at the time of my appointment 
      • Staying in the pharmacy for no less than 15 minutes (and up to 30 minutes) after my vaccination to allow for appropriate monitoring from the vaccination team for adverse effects or reactions

      For the health and safety of the pharmacy staff and other patrons, all patients are required to follow the above policies in their entirety. 

       

      I understand that Lebanon Shops Pharmacy is following the guidelines and phases set forth by the CDC and the Pennsylvania Department of Health. I will receive submission confirmation and appointment booking information via email. 

       

      I permit Lebanon Shops Pharmacy to process my vaccination through my insurance, prescription or medical, as necessary. 

       

      I permit Lebanon Shops Pharmacy to report my vaccinations to the State and Federal government, as required, including recordkeeping through the Pennsylvania Statewide Immunization Information System (PA-SIIS), and to my PCP or general practitioner. 

       

      I acknowledge that the COVID-19 vaccine, regardless of manufacturer, is not 100% effective, even after multiple doses.

       

      I acknowledge that my vaccination will be given by a certified and trained pharmacy staff member that has been designated as part of the vaccination team.

       

      I am aware that the staff member administering my vaccine is subject to availability at the time of the appointment, which may include any of the vaccinators listed below or a student pharmacist volunteer. 

      [We appreciate your patience and flexibility!]


      Vaccinators include:

      • Diane Riley, RN, BSN, Head of Clinical Services
      • Tom Riley, RPh, Owner, Pharmacist in Charge
      • Kristi Riley, PharmD, RPh, Certified Immunizer

       

      (Please note: Student pharmacists administering the vaccine are licensed to practice as a student in the state of Pennsylvania, certified to administer injectables, and have been thoroughly trained by Duquesne University School of Pharmacy or University of Pittsburgh School of Pharmacy, the American Pharmacists Association, and Lebanon Shops Pharmacy.)

    • Agree 

    • I understand the benefits and risks of the COVID-19 vaccine as described in the Moderna Emergency Use Authorization (EUA), the Pfizer Emergency Use Authorization, the Novavax Emergency Use Authoriazation (EUA) a copy of which I was provided with this Consent and Release (through each link).

      I am also aware that the CDC recommends that I sign up for V-Safe After-Vaccination monitoring, which I have also received the relevant information through the link located in this form.

      I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a person for whom I represent that I am authorized to sign this Consent and Release.

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    • Vaccine Schedule Graphic 
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    • Vaccine 

    • Please Read Carefully

      Terms and Conditions:

      I agree to follow the policies set forth by Lebanon Shops Pharmacy and the vaccination team to protect myself, the staff, and other patients present in the pharmacy, which includes:

      • Arriving on time to my appointment, as any patient not on time risks being required to reschedule to maintain social distancing
      • Bringing my current ID to the appointment
      • Bringing my insurance card or Medicare/Medicaid card to the appointment (if applicable)
      • Participation in symptom screening, including a COVID-19 symptom questionnaire and a temperature check, if requested by pharmacy staff
      • Answering or filling out any additional screening questionnaires as required by law or the pharmacy at the time of my appointment 
      • Staying in the pharmacy for no less than 15 minutes (and up to 30 minutes) after my vaccination to allow for appropriate monitoring from the vaccination team for adverse effects or reactions

      For the health and safety of the pharmacy staff and other patrons, all patients are required to follow the above policies in their entirety. 

       

      I understand that Lebanon Shops Pharmacy is following the guidelines and phases set forth by the CDC and the Pennsylvania Department of Health. I will receive submission confirmation and appointment booking information via email. 

       

      I permit Lebanon Shops Pharmacy to process my vaccination through my insurance, prescription or medical, as necessary. 

       

      I permit Lebanon Shops Pharmacy to report my vaccinations to the State and Federal government, as required, including recordkeeping through the Pennsylvania Statewide Immunization Information System (PA-SIIS), and to my PCP or general practitioner. 

       

      I acknowledge that the COVID-19 vaccine, regardless of manufacturer, is not 100% effective, even after multiple doses.

       

      I acknowledge that my vaccination will be given by a certified and trained pharmacy staff member that has been designated as part of the vaccination team.

       

      I am aware that the staff member administering my vaccine is subject to availability at the time of the appointment, which may include any of the vaccinators listed below or a student pharmacist volunteer. 

      [We appreciate your patience and flexibility!]


      Vaccinators include:

      • Diane Riley, RN, BSN, Head of Clinical Services
      • Tom Riley, RPh, Owner, Pharmacist in Charge
      • Kristi Riley, PharmD, RPh, Certified Immunizer

       

      (Please note: Student pharmacists administering the vaccine are licensed to practice as a student in the state of Pennsylvania, certified to administer injectables, and have been thoroughly trained by Duquesne University School of Pharmacy or University of Pittsburgh School of Pharmacy, the American Pharmacists Association, and Lebanon Shops Pharmacy.)

    • **Please be aware - the J&J vaccine is no longer available for distribution per the Pennsylvania Department of Health. 

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    • Clear

    • By clicking the "Submit" button on the following page, 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. This form is HIPAA compliant and will only be viewed by approved staff of Lebanon Shops Pharmacy (the vaccination team). 

  • Next Step: Scheduling Your Appointment

  • After hitting the submit button below,

    you will receive a confirmation email shortly and be able to schedule your appointment!

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    1. You will be emailed a link to book your appointment 

    The email will be sent to {email}

    If this is incorrect and you would like to schedule at a later time, please correct this by hitting the "Back" button below and inputting the email that you would like to use 

     

    2. After clicking submit, you will be immediately redirected into our COVID-19 appointment site 

    Please answer the 3 questions to view the schedule 

     

     

    We look forward to seeing you for your vaccine and keeping you and your family healthy!

     

    - Your Friends at Lebanon Shops Pharmacy

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