Fillable Spartan Pharmacy Vaccine Consent Form 01 25 2021 (Triadex Services)

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Spartan Pharmacy Vaccine Consent Form 01 25 2021 (Triadex Services)

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The Spartan Pharmacy Vaccine Consent Form 01 25 2021 (Triadex Services) form is 4 pages long and contains:

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  • 57 check-boxes
  • 46 other fields

Country of origin: US
File type: PDF

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VACCINE CONSENT FORM
3526 Brownsville Road
Phone: 412.884.4400
M-F: 9 am - 7 pm
Sat: 9 am - 4 pm
Sun: 10 am - 2 pm
3520 Saw Mill Run Blvd
Phone: 412.440.5888
Everyday: 8 am - 8 pm
3400 South Park Road
Phone: 412.831.1333
M-F: 9 am - 7 pm
Sat: 9 am - 4 pm
Sun: 10 am - 2 p
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
q Twinrix (Hep A/Hep B combo) Doses at 0,1 and 6 months
q Vaqta (Hep A) Doses at 0 and 6-18 mos
q Energix-B 20mcg/ml -Doses at 0, 1 and 6 months
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 1 OF 10
IF YOU ARE REQUESTING A
COVID-19 VACCINE, PLEASE
SKIP PAGE 2 AND ANSWER THE
COVID-19 SPECIFIC QUESTIONS
BEGINNING ON PAGE 3.
click to sign
signature
click to edit
click to sign
signature
click to edit
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 CONSENT FORM
PAGE 2 OF 10
VACCINE
COVID-19 (1st dose)
COVID-19 (2nd dose)
INFLUENZA
TWINRIX (HepA/B)
VAQTA (Hep A)
ENERGIX (Hep B)
MMR II
PREVNAR 13 (PCV 13)
PNEUMOVAX 23
SHINGRIX (1st dose)
SHINGRIX (2nd dose)
TD
BOOSTRIX (Tdap)
OTHER:
VIS DATE
12/20/20
12/20/20
8/15/19
07/20/16
07/20/16
08/15/19
08/15/19
10/30/19
10/30/19
10/30/19
10/30/19
04/11/17
04/01/20
DATE
SITE/ROUTE MANUF./LOT NO DATE VIS GIVEN
Vaccine Adminstered By
______________________________________________________________
Title
______________________________________
01/05/2021
CS321629-E
1
For vaccine recipients:
The following questions will help us determine if there is
any reason you should not get the COVID-19 vaccine today.
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.
If a question is not clear, please ask your healthcare provider to explain it.
Adapted with appreciation from the Immunization Action Coalition (IAC) screening checklists
Patient Name
Age
Yes No
Don't
know
Form reviewed by Date
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?
Pzer 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?
Prevaccination Checklist
for COVID-19 Vaccines
PAGE 3 OF 10
PAGE 4 OF 10
Revised: 12/2020 1
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 or
smell; sore throat; congestion or runny nose; nausea or vomiting; diarrhea.
WHAT IS THE MODERNA COVID-19 VACCINE?
The Moderna COVID-19 Vaccine is an unapproved vaccine that may prevent COVID-19. There
is no FDA-approved vaccine to prevent COVID-19.
The FDA has authorized the emergency use of the Moderna COVID-19 Vaccine to prevent
COVID-19 in individuals 18 years of age and older under an Emergency Use Authorization
(EUA).
For more information on EUA, see the “What is an Emergency Use Authorization (EUA)?”
section at the end of this Fact Sheet.
PAGE 5 OF 10
Revised: 12/2020 2
WHAT SHOULD YOU MENTION TO YOUR VACCINATION PROVIDER BEFORE
YOU GET THE MODERNA COVID-19 VACCINE?
Tell your vaccination provider about all of your medical conditions, including if you:
• have any allergies
• have a fever
• have a bleeding disorder or are on a blood thinner
• are immunocompromised or are on a medicine that affects your immune system
• are pregnant or plan to become pregnant
• are breastfeeding
• have received another COVID-19 vaccine
WHO SHOULD GET THE MODERNA COVID-19 VACCINE?
FDA has authorized the emergency use of the Moderna COVID-19 Vaccine in individuals 18
years of age and older.
WHO SHOULD NOT GET THE MODERNA COVID-19 VACCINE?
You should not get the Moderna COVID-19 Vaccine if you:
• had a severe allergic reaction after a previous dose of this vaccine
• had a severe allergic reaction to any ingredient of this vaccine
WHAT ARE THE INGREDIENTS IN THE MODERNA COVID-19 VACCINE?
The Moderna COVID-19 Vaccine contains the following ingredients: messenger ribonucleic acid
(mRNA), lipids (SM-102, polyethylene glycol [PEG] 2000 dimyristoyl glycerol [DMG],
cholesterol, and 1,2-distearoyl-sn-glycero-3-phosphocholine [DSPC]), tromethamine,
tromethamine hydrochloride, acetic acid, sodium acetate, and sucrose.
HOW IS THE MODERNA COVID-19 VACCINE GIVEN?
The Moderna COVID-19 Vaccine will be given to you as an injection into the muscle.
The Moderna COVID-19 Vaccine vaccination series is 2 doses
given 1 month apart.
If you receive one dose of the Moderna COVID-19 Vaccine, you should receive a second dose of
the same vaccine 1 month later to complete the vaccination series.
HAS THE MODERNA COVID-19 VACCINE BEEN USED BEFORE?
The Moderna COVID-19 Vaccine is an unapproved vaccine. In clinical trials, approximately
15,400 individuals 18 years of age and older have received at least 1 dose of the Moderna
COVID-19 Vaccine.
WHAT ARE THE BENEFITS OF THE MODERNA COVID-19 VACCINE?
In an ongoing clinical trial, the Moderna COVID-19 Vaccine has been shown to prevent
COVID-19 following 2 doses given 1 month apart. The duration of protection against COVID-19
is currently unknown.
PAGE 6 OF 10
Revised: 12/2020 3
WHAT ARE THE RISKS OF THE MODERNA COVID-19 VACCINE?
Side effects that have been reported with the Moderna COVID-19 Vaccine include:
• Injection site reactions: pain, tenderness and swelling of the lymph nodes in the same arm
of the injection, swelling (hardness), and redness
• General side effects: fatigue, headache, muscle pain, joint pain, chills, nausea and
vomiting, and fever
There is a remote chance that the Moderna COVID-19 Vaccine could cause a severe allergic
reaction. A severe allergic reaction would usually occur within a few minutes to one hour after
getting a dose of the Moderna COVID-19 Vaccine. For this reason, your vaccination provider
may ask you to stay at the place where you received your vaccine for monitoring after
vaccination. Signs of a severe allergic reaction can include:
• Difficulty breathing
• Swelling of your face and throat
• A fast heartbeat
• A bad rash all over your body
• Dizziness and weakness
These may not be all the possible side effects of the Moderna COVID-19 Vaccine. Serious and
unexpected side effects may occur. The Moderna COVID-19 Vaccine is still being studied in
clinical trials.
WHAT SHOULD I DO ABOUT SIDE EFFECTS?
If you experience a severe allergic reaction, call 9-1-1, or go to the nearest hospital.
Call the vaccination provider or your healthcare provider if you have any side effects that bother
you or do not go away.
Report vaccine side effects to FDA/CDC Vaccine Adverse Event Reporting System
(VAERS). The VAERS toll-free number is 1-800-822-7967 or report online to
https://vaers.hhs.gov/reportevent.html. Please include “Moderna COVID-19 Vaccine EUA” in
the first line of box #18 of the report form.
In addition, you can report side effects to ModernaTX, Inc. at 1-866-MODERNA (1-866-663-
3762).
You may also be given an option to enroll in v-safe. V-safe is a new voluntary smartphone-based
tool that uses text messaging and web surveys to check in with people who have been vaccinated
to identify potential side effects after COVID-19 vaccination. V-safe asks questions that help
CDC monitor the safety of COVID-19 vaccines. V-safe also provides second-dose reminders if
needed and live telephone follow-up by CDC if participants report a significant health impact
following COVID-19 vaccination. For more information on how to sign up, visit:
www.cdc.gov/vsafe.
PAGE 7 OF 10
Revised: 12/2020 4
WHAT IF I DECIDE NOT TO GET THE MODERNA COVID-19 VACCINE?
It is your choice to receive or not receive the Moderna COVID-19 Vaccine. Should you decide
not to receive it, it will not change your standard medical care.
ARE OTHER CHOICES AVAILABLE FOR PREVENTING COVID-19 BESIDES
MODERNA COVID-19 VACCINE?
Currently, there is no FDA-approved alternative vaccine available for prevention of COVID-19.
Other vaccines to prevent COVID-19 may be available under Emergency Use Authorization.
CAN I RECEIVE THE MODERNA COVID-19 VACCINE WITH OTHER VACCINES?
There is no information on the use of the Moderna COVID-19 Vaccine with other vaccines.
WHAT IF I AM PREGNANT OR BREASTFEEDING?
If you are pregnant or breastfeeding, discuss your options with your healthcare provider.
WILL THE MODERNA COVID-19 VACCINE GIVE ME COVID-19?
No. The Moderna COVID-19 Vaccine does not contain SARS-CoV-2 and cannot give you
COVID-19.
KEEP YOUR VACCINATION CARD
When you receive your first dose, you will get a vaccination card to show you when to return for
your second dose of the Moderna COVID-19 Vaccine. Remember to bring your card when you
return.
ADDITIONAL INFORMATION
If you have questions, visit the website or call the telephone number provided below.
To access the most recent Fact Sheets, please scan the QR code provided below.
Moderna COVID-19 Vaccine website
www.modernatx.com/covid19vaccine-eua
(1-866-663-3762)
HOW CAN I LEARN MORE?
• Ask the vaccination provider
• Visit CDC at https://www.cdc.gov/coronavirus/2019-ncov/index.html
• Visit FDA at https://www.fda.gov/emergency-preparedness-and-response/mcm-legal-
regulatory-and-policy-framework/emergency-use-authorization
• Contact your state or local public health department
PAGE 8 OF 10
Revised: 12/2020 5
WHERE WILL MY VACCINATION INFORMATION BE RECORDED?
The vaccination provider may include your vaccination information in your state/local
jurisdiction’s Immunization Information System (IIS) or other designated system. This will
ensure that you receive the same vaccine when you return for the second dose. For more
information about IISs, visit: https://www.cdc.gov/vaccines/programs/iis/about.html.
WHAT IS THE COUNTERMEASURES INJURY COMPENSATION PROGRAM?
The Countermeasures Injury Compensation Program (CICP) is a federal program that may help
pay for costs of medical care and other specific expenses of certain people who have been
seriously injured by certain medicines or vaccines, including this vaccine. Generally, a claim
must be submitted to the CICP within one (1) year from the date of receiving the vaccine. To
learn more about this program, visit www.hrsa.gov/cicp/ or call 1-855-266-2427.
WHAT IS AN EMERGENCY USE AUTHORIZATION (EUA)?
The United States FDA has made the Moderna COVID-19 Vaccine available under an
emergency access mechanism called an EUA. The EUA is supported by a Secretary of Health
and Human Services (HHS) declaration that circumstances exist to justify the emergency use of
drugs and biological products during the COVID-19 pandemic.
The Moderna COVID-19 Vaccine has not undergone the same type of review as an FDA-
approved or cleared product. FDA may issue an EUA when certain criteria are met, which
includes that there are no adequate, approved, and available alternatives. In addition, the FDA
decision is based on the totality of the scientific evidence available showing that the product may
be effective to prevent COVID-19 during the COVID-19 pandemic and that the known and
potential benefits of the product outweigh the known and potential risks of the product. All of
these criteria must be met to allow for the product to be used during the COVID-19 pandemic.
The EUA for the Moderna COVID-19 Vaccine is in effect for the duration of the COVID-19
EUA declaration justifying emergency use of these products, unless terminated or revoked (after
which the products may no longer be used).
©2020 ModernaTX, Inc. All rights reserved.
Patent(s): www.modernatx.com/patents
Revised: 12/2020
PAGE 9 OF 10
Get vaccinated.
Get your smartphone.
Get started with v-safe.
10:18 AM
What is v-safe?
V-safe is a smartphone-based tool that uses text messaging and
web surveys to provide personalized health check-ins after you
receive a COVID-19 vaccination. Through v-safe, you can quickly
tell CDC if you have any side effects after getting the COVID-19
vaccine. Depending on your answers, someone from CDC may call
to check on you. And v-safe will remind you to get your second
COVID-19 vaccine dose if you need one.
Your participation in CDC’s v-safe makes a difference — it helps
keep COVID-19 vaccines safe.
How can I participate?
Once you get a COVID-19 vaccine, you can enroll in v-safe using
your smartphone. Participation is voluntary and you can opt out at
any time. You will receive text messages from v-safe around 2 p.m.
local time. To opt out, simply text “STOP” when v-safe sends you a
text message. You can also start v-safe again by texting “START.”
How long do v-safe check-ins last?
During the rst week after you get your vaccine, v-safe will send
you a text message each day to ask how you are doing. Then you
will get check-in messages once a week for up to 5 weeks. The
questions v-safe asks should take less than 5 minutes to answer.
If you need a second dose of vaccine, v-safe will provide a new
6-week check-in process so you can share your second-dose
vaccine experience as well. You’ll also receive check-ins 3, 6, and
12 months after your nal dose of vaccine.
Is my health information safe?
Yes. Your personal information in v-safe is protected so that it stays
condential and private.*
10:18 AM
Use your smartphone
to tell CDC about
any side effects after
getting the COVID-19
vaccine. You’ll also get
reminders if you need a
second vaccine dose.
Sign up with your
smartphone’s browser at
vsafe.cdc.gov
OR
Aim your smartphone’s
camera at this code
* To the extent v-safe uses existing information systems managed by CDC, FDA, and other federal
agencies, the systems employ strict security measures appropriate for the data’s level of sensitivity.
12/11/20
SM
PAGE 10 OF 10
How to register and use v-safe
You will need your smartphone and information about the COVID-19 vaccine you received. This
information can be found on your vaccination record card; if you cannot nd your card, please contact
your healthcare provider.
Register
1. Go to the v-safe website using one of the two options below:
Complete a v-safe health check-in
1. When you receive a v-safe check-in text message on your smartphone, click the link when ready.
2. Follow the instructions to complete the check-in.
OR
Use your smartphone’s
browser to go to
vsafe.cdc.gov
Aim your smartphone’s
camera at this code
Troubleshooting
How can I come back and finish a check-in
later if I’m interrupted?
Click the link in the text message reminder to restart
and complete your check-in.
How do I update my vaccine information after
my second COVID-19 vaccine dose?
V-safe will automatically ask you to update your
second dose information. Just follow the instructions.
Need help with v-safe?
Call 800-CDC-INFO (800-232-4636)
TTY 888-232-6348
Open 24 hours, 7 days a week
Visit www.cdc.gov/vsafe
U.S. Department of
Health and Human Services
Centers for Disease
Control and Prevention
2. Read the instructions. Click Get Started.
3. Enter your name, mobile number, and other requested information. Click Register.
4. You will receive a text message with a verification code on your smartphone. Enter the code in
v-safe and click Verify.
5. At the top of the screen, click Enter vaccine information.
6. Select which COVID-19 vaccine you received (found on your vaccination record card; if you cannot
find your card, please contact your healthcare provider). Then enter the date you were vaccinated.
Click Next.
7. Review your vaccine information. If correct, click Submit. If not, click Go Back.
8. Congrats! You’re all set! If you complete your registration before 2 p.m. local time, v-safe will start
your initial health check-in around 2 p.m. that day. If you register after 2 p.m., v-safe will start your
initial health check-in immediately after you register — just follow the instructions.
You will receive a reminder text message from v-safe when it’s time for the next check-in — around
2 p.m. local time. Just click the link in the text message to start the check-in.
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Spartan Pharmacy Vaccine Consent Form 01 25 2021 (Triadex Services)

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Completed 30 March 2021

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