VACCINE CONSENT FORM 1. Complete this interactive form online (click to type answers) 2. Print it out, sign it, and bring it with you when you come in for your appointment. 3526 Brownsville Road 3520 Saw Mill Run Blvd 3400 South Park Road Phone: 412.884.4400 Phone: 412.440.5888 Phone: 412.831.1333 M-F: 9 am - 7 pm Everyday: 8 am - 8 pm M-F: 9 am - 7 pm Sat: 9 am - 4 pm Sat: 9 am - 4 pm Sun: 10 am - 2 pm Sun: 10 am - 2 p VACCINE CONSENT FORM PAGE 1 OF 10 Name _____________________________________________________________________________________________________________________________ Date of Birth _________________________________________________________________ (Must be 4 or older) Sex: q Male q Female Address __________________________________________________________________________________________________________________________ City/State/Zip ____________________________________________________________________________________________________________________ Home Phone (__________)_________________________________________ Cell Phone (__________)_________________________________________ Insurance Name __________________________________________________________________________________________________________________ Insurance ID Number _____________________________________________________________________________________________________________ Insurance Group Number _________________________________________________________________________________________________________ PCP Name ______________________________________________________________ PCP Phone (__________)__________________________________ PATIENT CONSENT 1. I have had a chance to ask questions and they were answered to my satisfaction. I understand the risks and benefits and ask that the injection or vaccine be given to me or to the person for whom I am authorized to make this request. 2. I have received a copy of the Vaccine Information Statement for the vaccine I will receive today: q COVID-19 (two doses) q Influenza IF YOU ARE REQUESTING A q Twinrix (Hep A/Hep B combo) Doses at 0,1 and 6 months COVID-19 VACCINE, PLEASE SKIP PAGE 2 AND ANSWER THE q Vaqta (Hep A) Doses at 0 and 6-18 mos COVID-19 SPECIFIC QUESTIONS q Energix-B 20mcg/ml -Doses at 0, 1 and 6 months BEGINNING ON PAGE 3. q Gardasil 9 – repeat doses depending on age q MMR II – one dose q Menveo (meningococcal ACWY) –one dose q Bexsero (meningococcal B) – doses at 0 and 2 months q Prevnar 13 (pneumococcal) -1 dose q Pneumovax 23 (pneumococcal) – 1 dose q Shingrix (Shingles) – doses at 0 and 2-6 months q Td (tetanus) – 1 dose q Boostrix (Tdap) – 1 dose q Varivax (varicella) – doses at 0 and 1 month 3. FINANCIAL RESPONSIBILITY – By my signature below, I acknowledge that I have received the vaccine indicated above and authorize Spartan Pharmacy to bill and collect from my insurance for the vaccine and administration fees. If my insurance denies payment for the entire or partial amount, I agree to be personally and fully responsible for payment. Signature ____________________________________________________________________________ Date ______________________________________ Signature of parent/guardian ________________________________________________________ Date ______________________________________ VACCINE CONSENT FORM PAGE 2 OF 10 PATIENT SCREENING QUESTIONS 1. Are you sick today? q Y q N 2. Do you have allergies to medications, eggs, latex or vaccines? q Y q N 3. Have you ever had a serious reaction after receiving a vaccine? q Y q N 4. Have you received a vaccine in the last 4 weeks? q Y q N 5. Are you pregnant or chance you can become pregnant in the next month? q Y q N 6. Do you have any problems with your immune system or take medications which affect your immune system? q Y q N 7. Do you have a long-term health problem (heart disease, lung disease, asthma, kidney disease, anemia or other blood disorder? q Y q N 8. Do you or anyone living in your household have cancer, leukemia, HIV/AIDS or another immune system problem? q Y q N 9. Have you travelled outside of the country in the last 4 weeks? q Y q N Please elaborate on any questions you answered YES: ___________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ Questions Answered by _______________________________________________________________ Date ______________________________________ Responses Reviewed by ______________________________________________________________ Date ______________________________________ FOR PHARMACY USE ONLY VACCINE DATE SITE/ROUTE MANUF./LOT NO VIS DATE DATE VIS GIVEN COVID-19 (1st dose) 12/20/20 COVID-19 (2nd dose) 12/20/20 INFLUENZA 8/15/19 TWINRIX (HepA/B) 07/20/16 VAQTA (Hep A) 07/20/16 ENERGIX (Hep B) 08/15/19 MMR II 08/15/19 PREVNAR 13 (PCV 13) 10/30/19 PNEUMOVAX 23 10/30/19 SHINGRIX (1st dose) 10/30/19 SHINGRIX (2nd dose) 10/30/19 TD 04/11/17 BOOSTRIX (Tdap) 04/01/20 OTHER: Vaccine Adminstered By ______________________________________________________________ Title ______________________________________ Prevaccination Checklist for COVID-19 Vaccines For vaccine recipients: Patient Name The following questions will help us determine if there is any reason you should not get the COVID-19 vaccine today. Age If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions may be asked. Don't If a question is not clear, please ask your healthcare provider to explain it. Yes No know 1. Are you feeling sick today? 2. Have you ever received a dose of COVID-19 vaccine? • If yes, which vaccine product did you receive? Pfizer Moderna Another product 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 • Polysorbate • A previous dose of COVID-19 vaccine 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 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.) 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. 6. Have you received any vaccine in the last 14 days? 7. Have you ever had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19? 8. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? 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? 10. Do you have a bleeding disorder or are you taking a blood thinner? 11. Are you pregnant or breastfeeding? Form reviewed by Date 01/05/2021 CS321629-E Adapted with appreciation from the Immunization Action Coalition (IAC) screening checklists PAGE 3 OF 101 FACT SHEET FOR RECIPIENTS AND CAREGIVERS EMERGENCY USE AUTHORIZATION (EUA) OF THE MODERNA COVID-19 VACCINE TO PREVENT CORONAVIRUS DISEASE 2019 (COVID-19) IN INDIVIDUALS 18 YEARS OF AGE AND OLDER You are being offered the Moderna COVID-19 Vaccine to prevent Coronavirus Disease 2019 (COVID-19) caused by SARS-CoV-2. This Fact Sheet contains information to help you understand the risks and benefits of the Moderna COVID-19 Vaccine, which you may receive because there is currently a pandemic of COVID-19. The Moderna COVID-19 Vaccine is a vaccine and may prevent you from getting COVID-19. There is no U.S. Food and Drug Administration (FDA) approved vaccine to prevent COVID-19. Read this Fact Sheet for information about the Moderna COVID-19 Vaccine. Talk to the vaccination provider if you have questions. It is your choice to receive the Moderna COVID-19 Vaccine. The Moderna COVID-19 Vaccine is administered as a 2-dose series, 1 month apart, into the muscle. The Moderna COVID-19 Vaccine may not protect everyone. This Fact Sheet may have been updated. For the most recent Fact Sheet, please visit www.modernatx.com/covid19vaccine-eua. WHAT YOU NEED TO KNOW BEFORE YOU GET THIS VACCINE WHAT IS COVID-19? COVID-19 is caused by a coronavirus called SARS-CoV-2. This type of coronavirus has not been seen before. You can get COVID-19 through contact with another person who has the virus. It is predominantly a respiratory illness that can affect other organs. People with COVID- 19 have had a wide range of symptoms reported, ranging from mild symptoms to severe illness. Symptoms may appear 2 to 14 days after exposure to the virus. Symptoms may include: fever or chills; cough; shortness of breath; fatigue; muscle or body aches; headache; new loss of taste