Adult – Lebanon Family Pharmacy

Do you qualify to receive the COVID-19 Vaccine (minimum age of 12)? *

Select an appointment time

Date *

Time *

First Name *

Middle Name *

Last Name *

Date of birth *

Phone Number *

Street Address *

Street Address1

City *

State *

Zip Code *

Gender at birth *

Race *

Ethnicity *

Mother's Maiden Name *

Required for proper vaccine documentation

Primary Care Provider Name

Emergency Contact Name *

Relationship to Emergency Contact *

COVID-19 Vaccine Screen Questions:
The following questions will help us determine your eligibility to be vaccinated today.

1. Do you feel sick today?

Yes
No
Don't Know

2. Have you ever received a dose of COVID-19 Vaccine?

Yes
No
Don't Know

3. Have you ever had an allergic reaction to a component of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures?

Yes
No
Don't Know

4. Have you ever had a history of allergic reaction or allergies to later, medications, food or vaccines (examples: polyethylene qlycol, polysorbate. eggs. bovine protein, gelatin, gentamicin, polymyxin, neomycin, phenol, yeast or thimerosal)?

Yes
No
Don't Know

5. Have you ever had an allergic reaction to a previous dose of COVID-19 Vaccine?

Yes
No
Don't Know

6. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?

Yes
No
Don't Know

7. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a component of COVID-19 vaccine, polysorbate, or any vaccine or injectable medication? This would include food, pet, environmental, or oral medication allergies.

Yes
No
Don't Know

8. Have you received any vaccine in the last 14 days?

Yes
No
Don't Know

9. Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19?

Yes
No
Don't Know

10. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? [note: monoclonal antibodies does not include antibiotics that you would be prescribed and filled at a pharmacy]

Yes
No
Don't Know

11. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?

Yes
No
Don't Know

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

Yes
No
Don't Know

13. Are you pregnant or breastfeeding?

Yes
No
Don't Know

Which arm would you like to get the injection on *

Left Arm
Right Arm

Consent (check each box below after reading and prior to signing the form)

I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet (the Pfizer Fact Sheet is available after clicking submit), a copy of which I was provided with this Consent Form. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent Form.

I understand that at this time, the COVID-19 vaccine requires 2 doses given 21-28 days apart depending on the manufacturer. If this is my second dose, I will bring my vaccine card with me to be completed.

I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.

I understand that I will be receiving the vaccination at no cost to me.

On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless the state of Tennessee Department of Health (TDOH), and their 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 vaccine listed in this form.

I acknowledge that: (a) I understand the purpose/benefits of TennIIS Tennessee immunization registry and (b) TDOH will include my personal immunization information and my personal immunization information will be shared with the Centers of Disease Control (CDC) or other federal agencies.

The vaccine is available to anyone who is insured. Please check the following if you have insurance.

If INSURED, check this box attesting to bringing in your prescription and medical insurance cards for your vaccine appointment. By selecting this, you are also authorizing the pharmacy to bill your insurance on your behalf for the immunization – understanding you will not incur any costs.

Please Upload Insurance Card *

Click or drag a file to this area to upload.

please select at least one of the following that you will bring with you to your appointment.

Social Security Number
State identification number and state of issuance
Driver's license number and state of issuance

Please Upload Supporting Document *

Click or drag a file to this area to upload.

Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):

Signature *

Date Signed *

Do you qualify to receive the COVID-19 Vaccine (age 5-11)? *

Select an appointment time

Date *

Time *

First Name *

Middle Name *

Last Name *

Date of birth *

Phone Number *

Street Address *

Street Address1

City *

State *

Zip Code *

Gender at birth *

Race *

Ethnicity *

Mother's Maiden Name *

Required for proper vaccine documentation

Primary Care Provider Name

Emergency Contact Name *

Relationship to Emergency Contact *

COVID-19 Vaccine Screen Questions:
The following questions will help us determine your eligibility to be vaccinated today.

1. Do you feel sick today?

Yes
No
Don't Know

2. Have you ever received a dose of COVID-19 Vaccine?

Yes
No
Don't Know

Yes
No
Don't Know

Yes
No
Don't Know

5. Have you ever had an allergic reaction to a previous dose of COVID-19 Vaccine?

Yes
No
Don't Know

6. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?

Yes
No
Don't Know

Yes
No
Don't Know

8. Have you received any vaccine in the last 14 days?

Yes
No
Don't Know

9. Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19?

Yes
No
Don't Know

Yes
No
Don't Know

11. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?

Yes
No
Don't Know

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

Yes
No
Don't Know

13. Are you pregnant or breastfeeding?

Yes
No
Don't Know

Which arm would you like to get the injection on *

Left Arm
Right Arm

Consent (check each box below after reading and prior to signing the form)

I understand that I will be receiving the vaccination at no cost to me.

The vaccine is available to anyone who is insured. Please check the following if you have insurance.

Please Upload Insurance Card *

Click or drag a file to this area to upload.

please select at least one of the following that you will bring with you to your appointment.

Social Security Number
State identification number and state of issuance
Driver's license number and state of issuance

Please Upload Supporting Document *

Click or drag a file to this area to upload.

Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):

Signature *

Date Signed *

Do you qualify to receive the COVID-19 Vaccine (minimum age of 12)? *

Select an appointment Date *

Select an appointment Time *

First Name *

Middle Name *

Last Name *

Date of birth *

Phone Number *

Street Address *

Street Address1

City *

State *

Zip Code *

Gender at birth *

Race *

Ethnicity *

Mother's Maiden Name *

Required for proper vaccine documentation

Primary Care Provider Name

Emergency Contact Name *

Relationship to Emergency Contact *

COVID-19 Vaccine Screen Questions:
The following questions will help us determine your eligibility to be vaccinated today.

1. Do you feel sick today?

Yes
No
Don't Know

2. Have you ever received a dose of COVID-19 Vaccine?

Yes
No
Don't Know

Yes
No
Don't Know

Yes
No
Don't Know

5. Have you ever had an allergic reaction to a previous dose of COVID-19 Vaccine?

Yes
No
Don't Know

6. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?

Yes
No
Don't Know

Yes
No
Don't Know

8. Have you received any vaccine in the last 14 days?

Yes
No
Don't Know

9. Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19?

Yes
No
Don't Know

Yes
No
Don't Know

11. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?

Yes
No
Don't Know

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

Yes
No
Don't Know

13. Are you pregnant or breastfeeding?

Yes
No
Don't Know

Which arm would you like to get the injection on *

Left Arm
Right Arm

Consent (check each box below after reading and prior to signing the form)

I understand that I will be receiving the vaccination at no cost to me.

The vaccine is available to anyone who is insured. Please check the following if you have insurance.

Please Upload Insurance Card *

Click or drag a file to this area to upload.

please select at least one of the following that you will bring with you to your appointment.

Social Security Number
State identification number and state of issuance
Driver's license number and state of issuance

Please Upload Supporting Document *

Click or drag a file to this area to upload.

Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):

Signature *

Date Signed *

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