COVID Vaccine Intake Consent Form Clinie taformation CVS pharmacy’ Glinie 1 Clinic Name Telephone ‘Store Number Address City State Zip Patient Information LastName First Name Date of Birth Gender Address City State Zip Primary Care Provider (PCP) Name PGP Phone Number PGP Fax Number PCP Address City State Zip Are youa resident © of a Long Term Care facility or an employee/staff member ©? Is this the patient's first © or second © dose of the COVID-19 vaccination? Insurance Information: (For onsite clinics, please ensure a copy of the patient's insurance card(s) was collected) * INDICATES REQUIRED FIELDS Prescription Insurance: O'Yes_©.No. *Are youthe primary cardholder? “fino, include the primary cardholder's DOB “Prescription BenefitPlanName “Cardholder ID # “RX Group ID “BIN “PON Medicare Fields: © Yes ONo “isthe Patient age 65 or older *Mecicare Part A/B ID Number (MB) Note: MBI i required for allpatients age 65 and or Medicare Eligible? older, or Medicare eligible. Refer to your Medicare Red, White, and Blue card Medical Insurance: “Medical insurance Provider SCardhoider ID *Group ID *Payor'D © Yes © No “Is the patient the primary cardholder? “af no, include primary cardholders DOB *Ifuninsured, you must check the box below to attest that the following information is true and accurate: Odo not have any insurance, including but not limited to Medicare, Medicaid or any other private or government-funded. health benefit plan. In order to have your vaccine administration fee paid for by the United States Health Resources & Services Administration's COVID-19 Program for Uninsured Patients, please pravide either (a) a valid Social Security number, (b) state identification number and state of issuance, OR (c) a driver's license number and the state of issuance. *Social Security Number or Stat Identification Number & State or Driver's License Number & State . co DON'T Potential Contraindications YES NO KNOW 1. Are you feeling sick today? ooo 2. Have you ever received a dose of COVID-19 vaccine? 000 Ifyes, which vaccine product? O Pfizer OModerna © Another product 3. Have you ever had a severe allergic reaction (e.g., anaphylaxis) in the past? Example: areaction for GG which you were treated with epinephrine or EpiPen®, or for which you had! to go to the hospital? . Was the severe allergic reaction after receiving a COVID-19 vaccine? oo 0 Was the severe allergic reaction after receiving another vaccine or injectable medication? 000 Was the severe allergic reaction related to receiving Polyethylene Glycol or products containing =) GG Polyethylene Glycol? Was the severe allergic reaction related to receiving Polysorbate or products containing Polysorbate?LastName First Name Potential Contraindications continued 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 6. Do youhave a bleeding disorder or are you taking a blood thinner? 7. For women, are you currently pregnant or breastfeeding? ‘CONSENT FOR SERVICES: have boon provided withthe Vacene Information ‘Shoot(s) or patient fact shoot corresponding to tho vacino(s that lam recetving. Ihave read the information provided about he vaccne | am to recave. Rave had the chance to ask questions that were answered to my salisfacion,lunderstand the benefits and risks of vaccination and Ivluntariy assume ful responsibty {or ary reactions that may result understand that | hou real ine vaccine ‘edmilatration area for 18 minutes afer tho vaccination tobe morstored for any ‘oto! sdvorso reactions. ' understand experience side ffcts that ahotks {othe folowing: callpharmacy, contact doctor, cal TL. request thatthe vaccine be avon tome orto the person named above for whom lam authorzedta make this request State of Georgia any: I very a pharmacist asked for my heath istory ‘and whether have Nada physal exam withinthe past year Heath care providers ‘Sel notidently condition(s) that would mean should not receive vaccines) [AUTHORIZATION TO REQUEST PAYMENT: Io hereby authorize CVS Ph (CUS to roloane information and request payment | Carty that the ino ‘gon by me in applying fr payment under Medicare or Medicaid, or x ‘Signature of patient to receive vaccine (or parent, guardian, or authorized representative) SE DonT YES NO KNOW oo 0 oo °o DONT YES No KNOW °oO0 oo ‘COVID-19 Prosram for Uninsurod Paton, is corect. authorize rlaase of all records to act on this request. raquest hat payment of authorized benetits be made on my banat DISCLOSURE OF RECORDS: undorstdl that CVS may be required to oF ay voluntary disclose my health information to the physician responsble for tis. protocol of specie health information of people vaccinated al CVS (fapplcable) fy Primary Care Physician (F thave one) my insurance plan, health systems and Iospitals, andlor state or federal registries, for purposes of treatment, payment oF ‘thor health eare operatons (euch as administration or quay assurance) 1 also “unorstard at CVS wll uso an ecto my hoalth information a sot for in the ‘CVS Notice of Prvacy Practices (2opy i avalabla in-store, onine or by requesting ‘8 paper copy trom the pharmacy). tate of Gaiforia only: agree to have GAR ‘Share my menunizaton data wih Heath Care Providers, agencies or soos Yaceine Cini Wl am recs a vaccine through a vaccine cic, [understand {hatmy name, vaccine appointment date and ine willbe proved to the cine ‘coordinator. Date of Birth Date If signing on bohalf of the pationt, 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) OL OR ioe Exp. Date Route Site If patient's body temperature is 100.4"F or greater, inform them they should not receive the vaccine at this time. Patient Temperature ‘Administering Immunizer Name & Title Administering Immunizer Signature To be filled out by immunizer, as required for state immunization registry reporting. Only for states listed. MS: Check all fields 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 O2-Asian Q3- Native Hawaiian/Other Pacific Islander O4- Black or African American OS-White 6- Other Race Ethnicity: O1-Hispanic O2-NotHispanic or Latino _O3- Unknown Next of Kin (18 or younger) Name Phone Number Relationship Address State of NJ only Prosoriber Address Proscriber Name 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: OYes ONo rate and Consent. intense for patent or earaqver nly I! youhave racaivesthe documantin ero, plase@roty CVS Pharmacy immediately