COVID-19 Vaccine Consent Form

    Phone number: 877-MEDS 247 or 717-893-7746 , Email: Info@medspack.com

    Section I. Personal Information

    Ethnicity:
    Race:
    Address:
    Primary care physician:
    Are you one of the following?:
    What dose of COVID-19 vaccine will this be?:

    Section II. Insurance Information

    *For 65 years and older or Medicare eligible
    If uninsured, you must check the box below to attest that the following information is true and accurate:

    Section III. Questionnaire for Immunization

    COVID-19 Screening Questions:
    Yes
    No
    I don't know or N/A
    In the past two weeks, have you tested positive for COVID-19 or are you currently being monitored for COVID-19?
    In the past two weeks, have you had a known exposure with anyone who tested positive for COVID-19?
    Have you had a 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?
    Questionnaire for Immunization:
    Yes
    No
    I don't know or N/A
    Have you received any vaccines in the past 14 days?
    Do you have an allergy to medications, foods, or any vaccines (eggs, gelatin, thimerosal, neomycin, gentamicin, latex, aluminum, preservatives, baker's yeast, etc.) or had severe allergic reaction for polyethylene glycol(commonly found in laxatives) or Polysorbate?
    Do you carry an EpiPen?
    Have you received COVID-19 monoclonal antibodies or convalescent plasma in the last 90 days?
    Have you ever had a serious reaction or fainted after receiving any vaccination?
    Have you ever had a seizure, brain disorder, or Guillain-Barre Syndrome?
    Are you pregnant or are you planning on becoming pregnant during the next month?
    Do you have a bleeding disorder or are you taking a blood thinner?
    Do you have a history of a weakened immune system?
    Do you have a history of an anaphylactic reaction for anything? (such as food, insect stings or a oral medications)

    Section IV. Appointment Scheduler

    Choose location:
    The Arc of Loudoun
    The Arc of Loudoun
    2021
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    Free appointments on 02/25/2021:
      No free appointments on that day
      Please pick another day

    Section V. Signatures

    I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA), a copy of which I was provided with this Consent and Release. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent and Release.

    Signature of Person to Receive Vaccine & EUA/VIS (or Signature of Parent/Guardian if Patient is < 18 yo):

    I have been provided with the Vaccine Information Sheet(s) or patient fact sheet corresponding to the vaccine(s) 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 benefits and risks of the 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 that if I experience side effects that I should: 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.

    AUTHORIZATION TO REQUEST PAYMENT: I do hereby authorize Medspack 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 Medspack Pharmacy may be required to or may voluntarily disclose my health information to the physician responsible for this protocol or specific health information of people vaccinated at Medspack, 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 Medspack Pharmacy will use and disclose my health information as set forth in the Medspack Pharmacy Notice of Privacy Practices (copy available by request or online).

    Consent for services:

    By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.