Potential Contraindications YES NO
DON’T
KNOW
4. Have you received any vaccines in the past 14 days?
5. Have you received monoclonal antibodies or convalescent plasma as part of a COVID-19 treatment
in the past 90 days?
Potential Considerations YES NO
DON’T
KNOW
6. Do you have a bleeding disorder or are you taking a blood thinner?
7. For women, are you currently pregnant or breastfeeding?
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
the benets 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 eects 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. State of Georgia only: I verify 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 vaccine(s).
AUTHORIZATION TO REQUEST PAYMENT: I do hereby authorize CVS Pharmacy®
(“CVS®”) 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 benets be
made on my behalf.
DISCLOSURE OF RECORDS: I understand that CVS® may be required to or may
voluntarily disclose my health information to the physician responsible for this
protocol of specic health information of people vaccinated at CVS (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 CVS will use and disclose my health information as set forth in the
CVS Notice of Privacy Practices (copy is available in-store, online or by requesting
a paper copy from the pharmacy). State of California only: I agree to have CAIR
share my immunization data with Health Care Providers, agencies or schools.
Vaccine Clinics: If I am receiving a vaccine through a vaccine clinic, I understand
that my name, vaccine appointment date and time will be provided to the clinic
coordinator.
X
Signature of patient to receive vaccine (or parent, guardian, or authorized representative) Date
If signing on behalf of the patient, you are stating that you are authorized to provide the required consents on behalf of the patient.
Name of parent, guardian, or authorized representative Phone Number Relationship
Vaccine Administration Information for Immunizer/Pharmacist use only
Administration Date Vaccine VIS Date Manufacturer Volume (mL)
Lot # Exp. Date Route Site
Patient Temperature
Administering Immunizer Name & Title Administering Immunizer Signature
To be lled out by immunizer, as required for state immunization registry reporting. Only for states listed.
MS: Check all elds for patients 18 years of age and younger
OK: Check Race and Ethnicity for all patients. Select Next of Kin for patients 18 years of age and younger.
Race: 1 - American Indian or Alaska Native 2 - Asian 3 - Native Hawaiian/Other Pacic Islander
4 - Black or African American 5 - White 6 - Other Race
Ethnicity: 1 - Hispanic 2 - Not Hispanic or Latino 3 - Unknown
Next of Kin (18 or younger)
Name Phone Number Relationship
Address
State of NJ only
Prescriber Name Prescriber 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:
Yes No
Form 2 of 2 to be completed
L R
Last Name First Name Date of Birth
Private and Condential. Intended for patient or caregiver only. If you have received this document in error, please notify CVS Pharmacy immediately.
V3 ©2020 CVS Health and/or one of its aliates. Condential and proprietary.
continued
If patient’s body temperature is 100.4˚F or greater, inform them they should not receive the vaccine at this time.
Version 3
