Secure Form

Welcome to Mediprocity

This is a COVID-19 Vaccine Consent Form that needs to be completed and signed to potentially receive the COVID-19 vaccine.

COVID-19 Vaccine Retail Consent Form
(for recipients that are not in facilities serviced by Mediprocity)

I consent to the vaccine

I decline consent to the vaccine

Facility Information

Facility Name

Facility Address

Facility Phone

Person receiving vaccine: *

employee/staff

resident

Recipient

Patient First Name: *

Patient Last Name: *

Patient Date of Birth: *

Patient Phone Number: *

Patient Sex:

M F Transgender / Other

Which dose of COVID-19 vaccination? *

First

Second

Booster - Must meet criteria

Which vaccine do you prefer?

Pfizer (first and second vaccine EUA) (booster EUA)

Moderna (first and second vaccine EUA) (booster EUA)

Janssen (J&J) 1st dose

Home address: *

City: *

State: *

Zip: *

MBI:

Medicaid #:

SS #: *

Do you have prescription insurance? *

Yes

If you are uninsured, you must check the box to attest that the following information is true and accurate:

In order to have your vaccine administration fee paid for by the United States Health Resources and Services Administration’s COVID-19 Program for Uninsured Patients, you must provide a valid Social Security number.

Consent for Services

“I hereby give my consent to the Pharmacy (‘Provider’) to administer the COVID-19 vaccine. I understand the risks and benefits associated with the COVID-19 vaccine and have received, read, and/or had explained to me the COVID-19 Vaccine Information sheet or patient fact sheet to the COVID-19 vaccine. I also acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction. On my own behalf and on behalf of my heirs, executors, administrators, trustees, legal representatives, and assigns, I hereby release and hold harmless the applicable Provider, its staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors, and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the COVID-19 vaccine.

I understand that, depending on my state’s law, I may need to specifically consent, and to the extent required by my state’s law, by signing below I hereby consent to the Provider reporting my Immunization Information to the State Immunization Information System. I understand that if I do not consent, my state’s or federal laws may permit certain disclosures of my immunization information as required or permitted by law.

I voluntarily authorize and direct my healthcare provider to use or disclose my health information during the term of this Authorization to the physician responsible for the protocol, my Primary Care Physician, my insurance and/or state or federal registries where required, for the purpose of treatment, payment, or other healthcare operations.

I consent to vaccine services:

Yes

If you are signing on behalf of the vaccine recipient please check this box.

Signature of patient to receive vaccine
(or parent, guardian, or authorized representative) *

( - ) show alternative signature box

Date

I accept the legal terms and conditions

Welcome to Mediprocity

COVID-19 Vaccine Retail Consent Form (for recipients that are not in facilities serviced by Mediprocity)

Facility Information

Recipient

COVID-19 Vaccine Retail Consent Form
(for recipients that are not in facilities serviced by Mediprocity)