Secure Form

COVID-19 VACCINATION SCREENING AND CONSENT UNDER EMERGENCY USE AUTHORIZATION

Please complete the following information for the person receiving the COVID-19 vaccine.

PATIENT DEMOGRAPHIC INFORMATION

LAST NAME:

FIRST NAME:

MIDDLE INITIAL:

DATE OF BIRTH:

SEX:

Male

Female

Transgender

Other

ADDRESS:

CITY:

STATE:

ZIP:

COUNTY:

HOME PHONE:

CELL PHONE:

EMAIL:

Private or employer insurance

Uninsured

Medicare

Medicaid

I have reviewed the V-Safe link on the vaccine

View V-Safe Link

Show the Sterling Pharmacy notice of privacy practices

I have reviewed the Sterling Pharmacy notice of privacy practices

Date form completed:

Please upload your Insurance Card. Do not upload your pharmacy benefits card. If you do not have insurance upload the front and back of your Driver’s License.

No Insurance or Guardian

The Public Readiness and Emergency Preparedness Act (PREP Act) authorizes the CICP to provide benefits to certain individuals or estates of individuals who sustain a covered serious physical injury as the direct result of the administration or use of the covered countermeasures. The CICP can also provide benefits to certain survivors of individuals who die as a direct result of the administration or use of covered countermeasures identified in a PREP Act declaration. The PREP Act declaration for medical countermeasures against COVID-19 states that the covered countermeasures are any antiviral medication, any other drug, any biologic, any diagnostic, any other device, or any vaccine used to treat, diagnose, cure, prevent, or mitigate COVID-19, the transmission of SARS-CoV–2 or a virus mutating from SARS-CoV-2, or any device used in the administration of and all components and constituent materials of any such product. Information about the CICP and filing a claim is available by calling 1-855-266-2427 or visiting
https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/pfizer-biontech-covid-19-vaccine or
https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/moderna-covid-19-vaccine

PLEASE PRINT NAME of signature below

SIGNATURE OF PATIENT:

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RELATIONSHIP TO CLIENT

TODAY’S DATE

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I, , acknowledge and agree that I have received or have been advised of the Missouri Department of Health and Senior Services’ Notice of Privacy Practices and where I can obtain any revisions made to this Notice.

CLIENT SIGNATURE/LEGAL REPRESENTATIVE:

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RELATIONSHIP TO CLIENT

TODAY’S DATE

I accept the legal terms and conditions

HEALTH HISTORY	YES	NO	UNKNOWN
1. Are you feeling sick today?
2. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something? For example, a reaction for which you were treated with epinephrine or Epi Pen or for which you had togo to the hospital?
3. Have you ever had a serious reaction after any vaccination or injectable medication including a previousdose of the COVID-19 vaccine?
4. In the past 14 days have you had contact with a confirmed COVID-19 patient?
5. Are you breastfeeding or pregnant?
6. Have you received passive antibody therapy as a treatment for COVID-19?
7. Are you immunocompromised? (taking medication or being treated for cancer, leukemia, HIV/AIDS orother immune system problems or taking medication that affects your immune system)
8. Do you have a bleeding disorder or are you taking a blood thinner?
Most recent Vaccine Dose Details Date of Last Dose Manufacturer of Last Dose: Moderna Pfizer Johnson & Johnson Primary dose: Booster dose: Dose#: 1 2 3