COVID-19 Vaccine Prescreening - Yorkville Pharmacy

If you have not made an appointment yet, please do so before filling out this form. Schedule an Appointment

General Info

First Name *

Last Name *

DL Number

Street Address *

City *

State *

Zip *

Phone *

Date of Birth (mm/dd/yyyy) *

Gender *

Ethnicity *

Race *

Primary Physician

Medicare Number (Part B)

Do you have insurance other than Medicare?

If so, Insurance Carrier and ID

Make sure to bring a copy of your insurance card to your appointment.

Emergency Contact - Name *

Emergency Contact - Relation *

Emergency Contact - Phone *

Administration Site for Vaccine *

Left/Right Deltoid is the most common choice.

Release of Information / Assignment of Insurance Benefits

I believe I understand the benefits and risks of the vaccine I have selected and ask that the vaccine be given to me or to the person named above for whom I am authorized to make this request. Under HIPAA provisions, I authorize the release of information about my immunization status and health status for continuing health services only which may include my referring physician or other health care agencies assigned to my care. All health information provided is held in strict confidence, following HIPAA regulations. I acknowledge receipt of Notice of Privacy Practices from Yorkville Pharmacy. Medicare or 3rd party patients: I do herby authorize Yorkville Pharmacy to release information and request payment for immunization services. I certify that the information given by me in applying for payment under Medicare or any 3rd party is correct. I authorize release of all records to act on this request. I request that payment of authorized benefits be made on my behalf. Should any information provided prove incorrect, thus denying payment, I personally guarantee payment for services rendered on my behalf and may be billed accordingly.

Signature

Reset Signature

Date *

Immunization Screening

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

If you have received a dose of COVID-19 vaccine, please answer all of the following that apply.

Please list the manufacturer (example: Pfizer, Moderna) and the date of your 1st dose.

Please list the manufacturer (example: Pfizer, Moderna) and the date of your 2nd dose.

Please list the manufacturer (example: Pfizer, Moderna) and the date of your 3rd dose.

Please list the manufacturer (example: Pfizer, Moderna) and the date of your 4th dose.

Will this be your: *

2nd Dose

3rd Dose

Please read and acknowledge the following: *

It has been at least 28 days after completion of the initial series.
I have made an appointment to get the same vaccine product as the initial two-dose mRNA COVID-19 vaccine series (Pfizer-BioNTech or Moderna).
I am attesting that I meet the following criteria of being immunocompromised below.

Currently, CDC is recommending that moderately to severely immunocompromised people receive an additional dose. This includes people who have:

Active treatment for solid tumor and hematologic malignancies
Receipt of solid-organ transplant and taking immunosuppressive therapy
Receipt of CAR-T-cell or hematopoietic stem cell transplant (within 2 years of transplantation or taking immunosuppression therapy)
Moderate or severe primary immunodeficiency (e.g., DiGeorge syndrome, Wiskott-Aldrich syndrome)
Advanced or untreated HIV infection
Active treatment with high-dose corticosteroids (i.e., ≥20mg prednisone or equivalent per day), alkylating agents, antimetabolites, transplant-related immunosuppressive drugs, cancer chemotherapeutic agents classified as severely immunosuppressive, tumor-necrosis (TNF) blockers, and other biologic agents that are immunosuppressive or immunomodulatory.

I acknowledge

Have you received any vaccine in the last 14 days? *

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

Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? *

[note: monoclonal antibodies does not include antibiotics that would be prescribed to you and filled at a pharmacy]

Have you ever had a reaction to any vaccine? *

Please describe:

Do you have any drug or food allergies? *

Please describe:

(How are you today?) Are you experiencing substantial fever, diarrhea, or vomiting today? *

Please describe:

Are you being treated by a doctor for a disease? *

Please describe:

Which medications do you take? *

Do you have any form of cancer, leukemia, or immune system problem (for example, taking cortisone, prednisone or other steroids, anticancer drugs, or x-ray treatments)? *

Please describe:

Have you received a transfusion of blood or plasma or any medicine containing antibodies (immune or gamma globulin) in the past year? *

Please describe:

For women: Are you pregnant or is there a chance you could become pregnant in the next 3 months?

Do you smoke cigarettes? *

Did you quit smoking recently?

Do you breathe in a lot of other people's smoke? *

I agree to be vaccinated today. I have received and understand information about the vaccine or vaccines I will receive. I have had my questions answered to my satisfaction. I authorize the provider performing this service to release to and access from my insurer (if applicable) and primary health care provider any medical or other information necessary. I authorize the payment of medical benefits to the provider performing this service.

Patient's Name *

Date *

Please download and read the following COVID-19 Fact Sheets. J&J EUA Fact Sheet, Moderna EUA Fact Sheet, Pfizer Age 12+ EUA Fact Sheet, Pfizer Age 5-11 EUA Fact Sheet, Novavax Fact Sheet

Consent (check each box below after reading and signing):

I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet (J&J EUA Fact Sheet, Moderna EUA Fact Sheet, Pfizer Age 12+ EUA Fact Sheet, Pfizer Age 5-11 EUA Fact Sheet, Novavax Fact Sheet), 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 Agree

I understand that I may be given a COVID-19 vaccine that requires 2 doses given 21-28 days apart depending on the manufacturer. If this is my first dose of the COVID-19 vaccine and it is 2 dose series, I intend to receive a second dose of the same vaccine in accordance with the timeframe specified in the Fact Sheet to complete the vaccination series.

I Agree

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 Agree

Please bring proof of eligibility to get the vaccine with you to your appointment.(ie, Id, work badge, meds to prove you fit in the current phase. You will be denied if you do not qualify for the current phase of vaccination approved by the state.

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