Covid-19 Form

* = Required Information

Patient Information

Last Name *

First Name *

Date of Birth *

Gender *

Race/Ethnicity *

Phone Number *

Address *

City *

State *

Zip

Insurance Information

Please ensure to record both pharmacy and medical insurance information since there are multiple ways that the vaccine administration can be billed at the pharmacy.

Non-Medicare	Pharmacy	Medical
Insurance Plan Name
Member/Recipient ID
RX Bin
RX PCN
Group Number

Medicare (Red, White & Blue Card) Number

Are you the cardholder?

Yes

Please provide cardholder's name, date of birth, and relationship.

Cardholder Name

Date of Birth

Relationship to Patient

Patient Consent

I understand the benefits and risks of the vaccination as described in the Emergency Use Authorization (EUA) and/or CDC Vaccine Information Statement (VIS), a copy of which was provided with this Consent and Release. I request the vaccine be given to me or the person named below, a minor for whom I represent that I am authorized to sign this Consent and Release.

Name of Person to Receive Vaccine (or Parent/Guardian, if a minor) *

Date

Print Parent/Guardian name if recipient is a minor

Date

I have received a copy of the notice of Privacy Practices. I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the Pharmacy and my rights with respect to my health information, including reporting to the State Vaccination Registry and/or local or state Departments of Heath, federal Department of Health and Human Services, and the Center for Disease Control and Prevention.

Name of Person to Receive Vaccine (or Parent/Guardian, if a minor) *

Date

Print Parent/Guardian name if recipient is a minor

Date

To be completed by Vaccine Administrator

Vaccine

Date Administered

Vaccine Lot Number

Expiration Date

MFR

Dosage

Injection Site

VIS/EUA Date

Dose #1 or #2

Administering Immunizer Name

Date