VaccEasy-Vaccine-Registration-form

Last Name *

First Name *

Middle Name

Address *

City *

State *

Zip *

Phone *

Mobile

DOB(MM/dd/yyyy) *

Gender *

Race/Ethnicity

Seasonal Influenza

Email *

Schedule Date *

Time (Mon - Fri 9 AM - 5 PM EST) *

Insurance information and authorization:

Insurance Provider Name

CardID

BIN

PCN

Medicare Card (MBI)(Red, Blue & White Card)

Uninsured (SSN)

Remarks / Notes for Pharmacy

Check only if applicable (The following questions will help us determine your eligibility for vaccination today.)

1. Are you pregnant?

2. Are you currently breastfeeding?

3. Have you had a severe allergic reaction (e.g., anaphylaxis, trouble breathing) to any vaccine or injectable therapy, or a history of anaphylaxis due to any cause?

4. Have you had a severe allergic reaction (e.g., anaphylaxis, trouble breathing) to any component of a COVID-19 vaccine, including lipid nanoparticles or polyethylene glycol (PEG)?

5. Have you received any other vaccine within the past 14 days or are scheduled to receive any vaccine in the next 14 days?

6. Have you received convalescent plasma or monoclonal/polyclonal antibody infusions for COVID-19 within the past 90 days?

7. Are you under age 16?

8. Are you currently sick? For example, are you currently experiencing fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, etc.?

9. Do you have a bleeding disorder or are you taking a blood thinner?

10. Have you tested positive for COVID-19 in the last 10 days?

11. Are you currently in quarantine for COVID-19 exposure?

12. Do you have any health conditions such as heart disease, diabetes or asthma?

13. Have you ever had a seizure disorder for which you are on seizure medication(s), a brain disorder, Guillain-Barré Syndrome (a condition that causes paralysis) or other nervous system problem?

14. Do you have a condition that may weaken your immune system (e.g., cancer, leukemia, lymphoma, HIV/AIDS or transplant)?

15. Have you received any vaccinations or skin tests in the past four weeks?

16. Are you currently on home infusions, weekly injections such as Humira™ (adalimumab), Remicade™ (infliximab) or Enbrel™ (etanercept), high-dose methotrexate, azathioprine or 6-mercaptopurine, antivirals, anticancer drugs or radiation treatments?

17. Are you currently taking high-dose steroid therapy (prednisone > 20 mg/day or equivalent) for longer than two weeks?

18. Have you received a transfusion of blood, blood products or been given a medication called immune (gamma) globulin in the past year?

19. Are you currently taking any antibiotics, antiviral or antimalarial medications? (Typhoid only)

20. Do you have a history of thrombocytopenia or thrombocytopenic purpura? (MMR only)

21. Are you receiving aspirin therapy or aspirin-containing therapy? (18 years of age and younger only)

22. Do you have a nasal condition serious enough to make breathing difficult (e.g., very stuffy nose)?

23. Have you ever received a dose of COVID-19 vaccine?

If yes, which product?

If yes, when was the date of your first dose?

Vaccine	MFR	Date admin.	Vaccine lot No.	Exp. date	Dosage	Injection site	VIS/EUA date	Dose in series
COVID-19
Influenza
Other

Consent for Vaccination I have reviewed my answers to the questions above with the vaccinator. If I experience any adverse reactions after leaving, I will notify my primary care provider. I have viewed the Emergency Use Authorization Fact Sheet provided to me today. I understand the benefits and risks of the vaccine. The vaccine checked above should be given to the person named above for whom I am authorized to make this request. I understand that I can review a Notice of Privacy Practice at the time of vaccination.
Signature/Name of Parent/Guardian/Patient/Immunizer name *

Date : *

Pharmacy Name CURLEW PHARMACY

Pharmacy Address 30226 US HWY 19 N, CLEARWATER, FL - 33761

Pharmacy Phone (727) 773-1600

Pharmacy Fax (727) 773-1700

Vaccine Administration Consent Form