COVID-19 Vaccine Consent - Kelley-Ross Pharmacy Group

After booking a Update Dose vaccine appointment with us, please complete and submit the consent form below prior to your visit

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Personal Information

I confirm that I am eligible*

Currently Eligible

Not Yet Eligible (Please Cancel Your Appointment Until You Are Eligible)

State Eligibility Guidelines

Name*

First Last

Birth Date*

MM slash DD slash YYYY

Gender*

Male

Female

Other

Home Phone*

Email*

Address*

Street Address Line 1 Street Address Line 2 City State ZIP Code

Is this your first, second, or a booster dose of COVID-19 vaccine?*

First Dose

Second Dose

Booster

Race*

Race is required by the state's immunization registry

Ethnicity*

Ethnicity is required by the state's immunization registry

Health Insurance

Please take photos of the front & back of your insurance card, and Medicare Card if you are over 65. Attach the images here (Click in each field below to upload your images):

(Front)

(BACK)

Medicare Card

If you DO NOT have health insurance, please answer the following attestation and provide one of the identification methods

You must attest that the following information is true and accurate (please skip if you have insurance):

I do not have any insurance including but not limited to Medicare, Medicaid, VA, military or any other private or government-funded health plan benefit.

To have your vaccination administration fee paid for by US HRSA, please provide either your Social Security Number or Driver’s License Number and state of issue

Social Security Number

Driver's License Number

State of Issue

General Health Screening Questions

The following questions will help us determine which vaccines you may be given today. If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions must be asked. If a question is not clear, please ask your health care provided to explain it.

Are you feeling sick today?*

Yes

Unsure

Have you ever had an allergic reaction to Polyethylene glycol (PEG), which is found in some medication such as laxative and preparation for colonoscopy procedures?*

Yes

Unsure

Have you ever had an allergic reaction to Polysorbate, which is found in some vaccines, film coated tablets and intravenous steroids?*

Yes

Unsure

Have you ever had an allergic reaction to previous dose of COVID-19 vaccine?*

Yes

Unsure

Have you ever had an allergic reaction to a vaccine or injectable therapy that contains multiple components, one of which is a COVID-19 vaccine component, but it is not know which component elicited the immediate reaction?*

Yes

Unsure

Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?*

Yes

Unsure

Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a component of COVID-19 vaccine, or any vaccine or injectable medication? This would include food, pet, venom, environmental, or oral medication allergies?*

Yes

Unsure

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

Unsure

Do you have a bleeding disorder or are you taking a blood thinner?*

Yes

Unsure

Are you pregnant or breastfeeding?*

Yes

Unsure

Do you have dermal fillers?*

Yes

Unsure

Check all the following that apply to you:

History of myocarditis or pericarditis

History of Multisystem Inflammatory Syndrome

History of immune-mediated syndrome defined by thrombosis and thrombocytopenia, like heparin-induced thrombocytopenia (HIT)

History of thrombosis with thrombocytopenia syndrome (TTS)

History of Guillain-Barre Syndrome (GBS)

History of COVID-19 disease within the past 3 months

Vaccine List

COVID-19 Screening Questions

In the past two weeks have you tested positive for COVID-19 or are you currently being monitored for COVID-19?*

Yes

Unsure

In the past two weeks, have you had contact with anyone who tested positive for COVID-19?*

Yes

Unsure

Have you had the new onset of fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, nausea, vomiting, or diarrhea?*

Yes

Unsure

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Today’s Date

MM slash DD slash YYYY

Consent, Authorization & Signature

By signing below, I certify the following:

Consent for services: I have been provided with the Vaccine Information Sheet(s) or patient fact sheet corresponding to the vaccine(s) that I am receiving. I have read the information provided about the vaccine I am to receive. I have had the chance to ask questions that were answered to my satisfaction. I understand that I am receiving a vaccine that has been approved through the Emergency Use Authorization process of the FDA. I understand the benefits and risks of vaccination and I voluntarily assume full responsibility for any reactions that may result. I understand that I should remain in the vaccine administration area for 15 minutes after the vaccination to be monitored for any potential adverse reactions. I understand if I experience side effects that I should do the following: call pharmacy, contact doctor, call 911. I request that the vaccine be given to me or to the person named above for whom I am authorized to make this request.

Authorization to request payment: I do hereby authorize Kelley-Ross Pharmacy (KR) to release information and request payment. I certify that the information given by me in applying for payment under Medicare or Medicaid, or the HSRA COVID-19 Program for uninsured patients, is correct. I authorize release of all records to act on this request. I request that payment of authorized benefits be made on my behalf.

Disclosure of records: I understand that KR may be required to or may voluntarily disclose my health information to the physician responsible for this protocol of specific health information of people vaccinated at KR (if applicable), my primary care physician (if I have one), my insurance plan, health systems and hospitals, and/or state or federal registries, for purposes of treatment, payment or other healthcare operations (such as administration or quality assurance). I also understand that KR will use and disclose my health information as set forth in the KR notice of privacy practices (copy is available in store, online, or by requesting a paper copy from the pharmacy). If I am receiving a vaccine through clinic, I understand that my name, vaccine appointment date and time will be provided to the clinic coordinator. I have answered the above questions knowing they represent risks to receiving vaccines. I have had a chance to ask questions that were answered to my satisfaction. I believe I understand the benefits and risks of the vaccines cited and ask that the vaccine(s) below to be given to me or to the person named above (for whom I am authorized to make this request.) I understand that it is recommended that I stay on the premises for 15 minutes after the vaccine is given in case of complications.

I hereby certify that I have received and/or read the pharmacy’s notice describing how medical information about me may be used and disclosed, and how I can gain access to this information.

I hereby certify that I have received and/or read the pharmacy’s notice describing how medical information about the patient I am signing for may be used and disclosed, and how I can gain access to this information.

Signature*

Use your mouse, finger, or stylus to sign in the space provided below.

Guardian Signature*

Guardian, please use your mouse, finger, or stylus to sign in the space provided below.

Next of Kin Name

First Last

Next of Kin Relationship

Next of Kin Address