hillrisepharmacy@gmail.com (575) 652-4499

COVID-19 Vaccine

COVID 19 vaccine is available for scheduling population as stipulated by New Mexico Dept Of Health. All appointments must fill this consent form below. Fill out this form mandatory CONSENT FORM to receive your appointment by email (appointments are limited due to vaccine supply)

Fill Consent form

VACCINE TYPE *

VACCINE DATE *

VACCINE TIME *

FIRST NAME *

MIDDLE NAME *

LAST NAME *

EMAIL ADDRESS *

DATE OF BIRTH *

AGE *

STREET ADDRESS *

CITY *

STATE *

ZIP/POSTAL CODE *

Mothers maiden last name and first name *

Daytime Phone *

Patient's Legal Representative

Relationship

Insurance Name and ID or Medicare PartB number *

Primary care Physician

Phone Number

Drivers ID *

Gender *

Male

Female

Ethnicity *

Unknown

Non Hispanic

Hispanic

Ethnicity *

American Indian/Alaska Native

White

Hawaiian Native or Other Pacific

African American

Not Stated

Asian

COVID-19 SCREENING QUESTIONS (Every row is required.)

Have you had a severe allergic reaction to this vaccine?+

Do you have a known history of a severe allergic reaction to any components of this vaccine such as lipids, potassium chloride, monobasic potassium phosphate, sodium chloride, dibasic sodium phosphate dihydrate or sucrose? (Full list of ingredients is available in the Fact Sheet for Vaccine Recipients and Caregivers or from your health care provider.)

Are you under the age of 18 years?

In the past two weeks (14 days) have you tested positive for COVID-19 or are you currently being monitored for COVID-19?

In the past two weeks (14 days) have you had exposure to a person 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?

MEDICAL SCREENING QUESTIONS (Every row is required.)

For patients: The following questions will help us determine which vaccine you may be given today. If you answer “yes” to anyquestion, it does not necessarily mean you should not be vaccinated. It just means that additional questions must be asked. If aquestion is not clear, please ask your health care provider to explain it. *

Do you have a history of severe allergic reaction (e.g., anaphylaxis) to another vaccine or injectable medication? If yes, what vaccine or injectable medication:

Do you have a bleeding disorder or are you on a blood thinner?

Are immunocompromised or are on a medicine that affects your immune system (such as cortisone, prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn’s disease or psoriasis; or have you had radiation treatments)?

Do you have any allergies (reactions to any vaccines or medications such as neomycin, polymyxin, thimerosal; foods such as eggs, gelatin, MSG; or latex)?

Have you experienced anaphylaxis or an allergic reaction requiring emergent care in the past?

In the past 2 weeks have you received any vaccinations such as MMR, Shingrix or Varicella, or received a TB skin test?

Do you have any long-term health problem such as heart disease, lung disease, liver disease, asthma, kidney disease, metabolic disease (ex: diabetes)?

Do you have cancer, leukemia, HIV/AIDS, rheumatoid arthritis, ankylosing spondylitis, Crohn’s disease, or any other immune system problem?

Have you had a seizure, brain, or other nervous system problem, such as Guillain-Barre Syndrome or other nervous system problems?

During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin, or an antiviral drug?

Are you pregnant or do you plan to become pregnant? If yes, please see important information below in section “About The Vaccine.”

Are you breastfeeding? If yes, please see important information below in section “About The Vaccine.”

ABOUT THE VACCINE

This Fact Sheet may have been updated. For the most recent Fact Sheet for Recipients and Caregivers, a copy of which is being provided to you with this informed consent. Current copies of the Fact Sheet are available online at https://www.modernatx.com and you should look here for updates.

The vaccine may prevent you from getting COVID-19. There is no U.S. Food and Drug Administration (FDA) approved vaccine to prevent COVID-19. The FDA has authorized the emergency use of this vaccine to prevent COVID-19 in individuals 18 years of age and older under an Emergency Use Authorization (EUA Note that pregnant and breastfeeding of women have not been included in clinical trials for the COVID-19 vaccine and the CDC Fact Sheet does not discuss any specific risks to these patients. Although theFDAoffersuse the vaccine for pregnant and breastfeeding women, the potential side effects are unknown at this time. Potential side effects to the mother, neonate or infant may include: miscarriage; birth defects; and serious injury or death to breastfeeding infants.

The vaccine will be given to you as an injection into the muscle. The vaccine is given in a series of 2 doses given 4 weeks apart. If you receive one dose of the vaccine, you should receive a second dose of this same vaccine 4 weeks later to complete the vaccination series.

Risks of the vaccine include side effects and there is a chance that the vaccine could cause a severe allergic reaction. If you experience a severe allergic reaction, call 9-1-1, or go tothe nearest hospital. Call the vaccination provider or your healthcare provider if you have any side effects that bother you or do not go away.

CONSENT FOR VACCINATION

I hereby authorize the administration of the COVID-19 vaccine to myself or to the person named below for whom I am the legal representative.

I have read or have had explained to me the information contained in the Fact Sheet for Recipients and Caregivers: Emergency Use Authorization EUA of COVID-19 Vaccine to PreventCoronavirus Disease 2019 COVID-19 and understand the risks and benefits of the vaccine and alternatives to the vaccine that is, not receiving the vaccine or waiting for otherversions of the vaccine If am pregnant or breastfeeding, I understand that the specific risks of the vaccine to pregnant and breastfeeding women are unknown at this time.

I have had the opportunity to ask questions about this immunization and any questions I had about the COVID-19 vaccine have been answered to my satisfaction

I believe the benefits outweigh the risks and I accept full responsibility for any reactions that may result from my receipt of the immunization or the receipt of the immunization by the person named below for whom I am the legal representative.

I agree that vaccine-related health information may be required to be or may voluntarily be disclosed to my health care provider, my insurance plan, and state or federal registries or other public health authorities, for purposes of treatment, payment or health care operations. I also agree that the organization providing my vaccine may use and disclose my health information as described in its Notice of Privacy Practices.

THIS CHECKONLY IF YOU ARE PREGNANT OR BREASTFEEDING: I understand that pregnant and breastfeeding women have not been included in clinical trials for the COVID-19 BOX vaccine. I understand that the specific risks of the COVID-19 vaccine to pregnant and breastfeeding women are unknown at this time and could include miscarriage, developmental damage, and/or death to breastfeeding children. Understanding this, I want to proceed with administration of the COViD-19 vaccine.Type option 5

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

DATE OF BIRTH *

Printed Name

Relationship to patient receiving vaccine (if not self)

If signing on behalf of the patient, you are stating that you are authorized to provide the required consent on behalf of the patient.

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