COVID-19 Vaccine Intake Form

COVID Vaccine Intake Consent Form 1A and 1B

Patient Information

Patient Name *

Date of Birth *

Email *

Phone *

Sex

Race

Ethnicity

Address *

Primary Care Provider (PCP) Name

Primary Care Provider (PCP) Phone

Primary Care Provider (PCP) Fax

Primary Care Provider (PCP) Address

1) If you are part of a Senior Facility clinic, which applies to you?

2) Are you a healthcare worker?

3) Are you 65 years or older?

4) Are you 16 years of age and older with at least one medical condition? *

5) Is this the patient's first or second dose of the COVID-19 vaccination? *

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Insurance Information (For onsite clinics, please ensure a copy of the patient's insurance card(s) was collected)

Prescription Insurance

Are you the primary care holder? *

If No, include the Primary Care Holder's Date Of Birth (DOB)

Prescription Benefit Plan Name

Cardholder ID #

RX Group ID

BIN

PCN

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Medicare Field

Is the Patient age 65 or older or Medicare Eligible? *

Medicare Part A/B ID Number (MBI) Note.

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Medical Insurance:

Medical Insurance Carrier

Cardholder ID #

Group ID

Payer ID

Are you the primary care holder? *

If No, include the Primary Care Holder's Date Of Birth (DOB)

Do you have Medicaid Insurance? *

ID#

State

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If uninsured, you must select the appropriate answer below to attest that the following information is true and accurate:

Do you have any insurance, including but not limited to Medicare, Medicaid or any other private or government-funded health benefit plan? *

Please note

Social Security Number

or State Identification Number & State

or Driver's License Number & State

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COVID-19 Screening Questions

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

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

3) 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? *

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To be filled out by the immunizer:

Patient Temperature:

Date

Note For Immunizer

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Immunization Screening Questions

1) Are you sick today? (For example: a cold, fever or acute illness) *

2) Do you have allergies or reactions to any foods, medications, vaccines or latex? (For example: eggs, gelatin, neomycin, thimerosal, etc.) *

3) Have you ever had a serious reaction after receiving a vaccination? Do you have a history of fainting, particularly with vaccines? Has any physician or other healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a medical setting? *

4) Have you had a seizure or a brain or other nervous system problem or Guillain Barre? *

5) Do you take anticoagulation medication? For example: warfarin, Coumadin or other blood thinner? *

6) Do you have a long-term health problem such as heart disease, lung disease, liver disease,asthma, kidney disease, metabolic disease (e.g., diabetes), anemia or other blood disorder? *

7) Do you have cancer, leukemia, HIV/AIDS, rheumatoid arthritis, ankylosing spondylitis, Crohn's disease or any other immune system problem? *

8) Do you have a weakened immune system or in past 3 months, taken medications that weaken it such as cortisone, prednisone, other steroids, anticancer drugs, or radiation treatments? *

9) During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug? *

10) For women, are you pregnant or is there a chance you could become pregnant during the next month? *

11) Have you received any vaccinations or TB skin test in the past 4 weeks? *

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 that I am to receive. I have had the chance to ask questions that were answered to my satisfaction. 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.

The state of Georgia only: I verify that a pharmacist asked for my health history and whether I have had a physical exam within the past year. Health care providers did not identify condition(s) that would mean I should not receive the vaccine(s).

AUTHORIZATION TO REQUEST PAYMENT: I do hereby authorize Zuriel Pharmacy to release information and request payment. I certify that the information given by me in applying for payment under Medicare or Medicaid, or the HRSA 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 Zuriel 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 Zuriel (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 health care operations (such as administration or quality assurance). I also understand that Zuriel will use and disclose my health information as set forth in the Zuriel Notice of Privacy Practices (copy is available in-store, online, or by requesting a paper copy from the pharmacy).

MODERNA COVID-19 FACTS SHEET

JANSSEN COVID-19 FACTS SHEET

ZURIEL PHARMACY PRIVACY POLICY

CONSENT: I have read, understand, agree, certify and/or authorize the information above and further agree to hold harmless Zuriel Pharmacy, including its employees, agents, and contractors from all liability and claims. I request that the vaccine be given to me or to the person named above for whom I am authorized to make this request.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature of patient to receive vaccine (or parent, guardian, or authorized representative) *

Date *

Please note

Name of parent, guardian, or authorized representative

Relationship

Phone Number

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Vaccine Administration Information for lmmunizer/Pharmacist use only

Administration Date

Vaccine

VIS Date

Manufacturer

Lot #

Exp. Date

Route

Site

Volume (mL)

Administering Immunizer Name & Title

Administering Immunizer Signature

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To be filled out by immunizer, as required for state immunization registry reporting. Only for states listed.

State of NJ only

Prescriber Name

Prescriber Address

MS: Select all fields for patients 18 years of age and younger

OK: Select Race and Ethnicity for all patients. Select Next of Kin for patients 18 years of age and younger.

Race

Ethnicity

Next of Kin (18 or younger)

Name

Phone Number

Relationship

Address

For CA, MA, MT, NJ, NM, NY, TX (For CA, this indicator means the registry will not share with universities, Schools, or other agencies)

Registry Sharing Indicator

How did you hear about us?

Private and Confidential. Intended for patient or caregiver only. If you have received this document in error, please notify Zuriel Pharmacy immediately. @2020 Omnicare

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Your Health, Our Priority

Patient Information

Insurance Information (For onsite clinics, please ensure a copy of the patient's insurance card(s) was collected)

Prescription Insurance

Medicare Field

Medical Insurance:

If uninsured, you must select the appropriate answer below to attest that the following information is true and accurate:

COVID-19 Screening Questions

To be filled out by the immunizer:

Immunization Screening Questions

Vaccine Administration Information for lmmunizer/Pharmacist use only

To be filled out by immunizer, as required for state immunization registry reporting. Only for states listed.

State of NJ only

Next of Kin (18 or younger)

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