Informed Consent for Immunization with COVID-19 Vaccine
M F Other
Last Name First Name Middle Date of Birth Age Gender
( ) -
Home Address
City
State Zip
Phone # Home Cell
Medicare Part B ID# or last 4 digits of SSN: _________________________________ Driver’s License #: __________________________________________________
Race: Asian Black or African American Hispanic American Indian Caucasian Pacific Islander Two or More Other: _______________________
Ethnicity: Hispanic or Latino Non-Hispanic or Latino Decline to State (Unknown)
Which arm do you prefer for vaccine? Enter weight IF LESS than 66 pounds: __________Lbs. Primary Care Provider Name: _____________________________
(Please circle) Left Right Primary Care Provider Address: ____________________________
Informed Consent: Please read and sign.
By my signature below, I consent to the administration of the vaccine(s) by a pharmacist or a supervised student pharmacist or technician, or other authorized person, where
permitted by law or state/federal guidance, employed or contracted by Albertsons Companies or one of its affiliated pharmacies and to be contacted at the number provided
above regarding other immunizations for which I am due or eligible to receive. I also release Albertsons Companies and its subsidiaries, affiliates, officers, directors, employees,
and agents from all liability, including acts of omission or commission, resulting, or arising from my receipt of this vaccination. I understand that: 1) I have voluntarily chosen to
receive the vaccination and understand that I am obligated to pay for all products and services received, if applicable. 2) I may be responsible for payment after the date of
service if the product or service is billed to my medical benefit. 3) I am of legal age and authorized to execute this consent form or I am the parent/guardian of the minor patient.
4) I will immediately alert the pharmacist of any medical conditions which may adversely affect my personal health or effectiveness of the vaccine. 5) I have been counseled
about potential side effects after vaccination, when they may occur, and when and where I should seek treatment. I am responsible for following up with my physician at my
expense if I experience any side effects. 6) I should remain in the area for observation for 15 minutes unless I have a history of an immediate allergic reaction of any severity to a
vaccine or injectable therapy or if I have a history of anaphylaxis due to any cause I should remain in the area for observation for 30 minutes after the vaccination. If I leave the
area without waiting, I acknowledge that I am doing so at my own risk and against the advice of the professional who administered the vaccine. 7) I have read, or have had read
to me, the Vaccine Information Statement(s) (“VIS”) or Emergency Use Authorization (“EUA”) provided for the vaccine(s) to be administered. I have had the opportunity to ask
questions, and all my questions have been answered to my satisfaction. I understand the benefits and risks of the vaccine(s). 8) I have been offered and/or provided a copy of
the company’s Notice of Privacy Practices in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 9) This vaccination, including any vaccination
granted additional privacy protections under state or federal law, is subject to reporting by my pharmacy or its business associate to an immunization registry, which may share
my immunization data with others, and to my primary care physician, the authorizing physician, or the local Department of Health, if applicable, and I authorize these
disclosures. (New Jersey Only: I authorize ___ do not authorize ___ reporting of my receipt of this vaccination to my primary care provider I understand that failure to check
authorize/do not authorize will serve as authorization.) (South Dakota and Massachusetts only: I understand I have the right to object to the sharing of my data to the above-
mentioned parties through such registries.)
X
Signature of Patient or Parent/Guardian of Minor Patient Date
For Pharmacy Use Only
Name of Administrator: ____________________ Administration Date: _____________ NPP Offered RPh Counseling (Please circle): Accepted / Declined
RPh Signature [Indicates (1) VIS/EUA Provided (2) Counseling Offered and (3) Patient Eligibility Verified]: __________________________________________________
WA ONLY: Substitution Permitted:_______________________________________ Dispense as Written:_________________________________________________
RxBIN: ____________________________ PCN: ____________________________ Group#: ___________________________ ID#: ______________________________
Medical (Name, ID#, Group#, Payer ID - if UHC): ________________________________________________________________________________________________
Billing Info (off-site only) Clinic Name: ________________________ Clinic Address: ___________________________________________________________________
Ver.1 2021
Please answer questions by checking the boxes.
Screening Questions – NOTE: IF COMPLETED ONLINE, REVIEW ANSWERS WITH PATIENT TO ENSURE NO CHANGES
1.
Are you sick today?
2.
Have you ever received a dose of COVID -19 vaccine?
If yes, which product did you receive? Pfizer Moderna Other: __________ Date: _____________
3.
Have you ever had an allergic reaction to a previous COVID-19 vaccine or any component of the COVID-19 vaccine, including
polyethylene glycol (PEG) or polysorbate?
Have you ever had an allergic reaction to another vaccine (other than COVID-19) or to an injectable medication?
5.
Have you ever had a severe allergic reaction (anaphylaxis) to any food, pet, environmental allergens, oral medications, or
latex? If yes, please list:
Have you received any vaccines in the past 14 days? (not a contraindication)
7.
Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as a treatment for COVID-19
within the last 90 days?
Are you pregnant or breastfeeding? (not a contraindication)
Vaccine Name Lot # Expiration Date Manufacturer Dose (ml) Dose # Route Site (circle) VIS/EUA Publication
R / L Deltoid
