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REFILLS
331-318-7905
COVID-19
Vaccine Administration Record
Name (Last):
Name (First):
Name (Middle):
Date of Birth:
Gender:
Race:
Address:
City:
State:
Zip:
Phone Number:
Primary Care Physician & Phone Number:
Emergency Contact Name:
Relation:
Phone Number:
Mother's Maiden Name:
1. Are you feeling sick today?
YES
NO
DON'T KNOW
2. Have you ever received a dose of COVID-19 Vaccine?
YES
NO
DON'T KNOW
If you have received a dose of COVID-19 Vaccine before:
Vaccine manufacturer (example: Pfizer, Moderna):
Date of first dose:
3. Have you ever had an allergic reaction to: (This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.)
- A component of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures.
YES
NO
DON'T KNOW
- Polysorbate
YES
NO
DON'T KNOW
- A previous dose of COVID-19 Vaccine
YES
NO
DON'T KNOW
4. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication? (This would include a severe allergic [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.)
YES
NO
DON'T KNOW
5. Have you ever had a severe allergic reaction (e,g., anaphylaxis) to something other than a component of COVID-19 vaccine, polysorbate, or any vaccine or injectable medication? This would include food, pet, environmental, or oral medication allergies?
YES
NO
DON'T KNOW
6. Have you received any vaccine in the last 14 days?
YES
NO
DON'T KNOW
7. Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19?
YES
NO
DON'T KNOW
8. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? [note: monoclonal antibodies does not include antibiotics that would be prescribed to you and filled at a pharmarcy]
YES
NO
DON'T KNOW
9. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
YES
NO
DON'T KNOW
10. Do you have a bleeding disorder or are you taking a blood thinner?
YES
NO
DON'T KNOW
11. Are you pregnant or breastfeeding?
YES
NO
DON'T KNOW
Name (PRINTED)
SIGNATURE
DATE
Name:
Date of Birth:
Consent (check each box below after reading and signing)
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet, a copy of which I was provided with this Consent 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 minor for whom I represent that I am authorized to sign this Consent Form.
I understand that at this time, the COVID-19 vaccine requires 2 doses given 21-28 days apart depending on the manfacturer.
If this is my second dose, I will bring my vaccine card with me to be completed.
I agree to stay in the vaccine administration area for fifteen (15) minutor or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate.
I understand that I will be receiving the vaccination at no cost to me.
If
insured
,
please bring in your prescription and medical insurance cards
for your vaccine appointment. I authorize the pharmacy to bill my insurance on my behalf for the immunization - understanding I will not incur any costs.
If
uninsured
, you must check the box below to attest that the following information is true and accurate:
I do not have any insurance, including but not limited to, Medicare, Medicaid, or any other private or government-unded benefit plan.
For
uninsured patients
, please select at least one of the following that you will bring with you to your appointment.
This is needed in order to have your vaccine administration fee paid for by the United States Health Resources & Services Administration's COVID-19 Program.
Social Security Number
State identification number and state of issuance
Driver's license number and state of issuance
Signature
Date
Send
