* = Required Information

Patient Information

Insurance Information

Please ensure to record both pharmacy and medical insurance information since there are multiple ways that the vaccine administration can be billed at the pharmacy.

Non-Medicare Pharmacy Medical
Insurance Plan Name
Member/Recipient ID
RX Bin
Group Number
Yes No
Please provide cardholder's name, date of birth, and relationship.

Patient Consent

I understand the benefits and risks of the vaccination as described in the Emergency Use Authorization (EUA) and/or CDC Vaccine Information Statement (VIS), a copy of which was provided with this Consent and Release. I request the vaccine be given to me or the person named below, a minor for whom I represent that I am authorized to sign this Consent and Release.

I have received a copy of the notice of Privacy Practices. I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the Pharmacy and my rights with respect to my health information, including reporting to the State Vaccination Registry and/or local or state Departments of Heath, federal Department of Health and Human Services, and the Center for Disease Control and Prevention.

To be completed by Vaccine Administrator
Security code