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Please fill out the form and the Pharmacy will contact you for the appointment.

Please do not call the pharmacy

Second dose patients, please call the pharmacy to confirm your date and time.

COVID Vaccine Consent Form
Gender
Race
Ethnicity
Resident / Work in Fairfax County?
Insurance Information: ( please bring the patient's insurance card(s) and ID)
*INDICATES REQUIRED FIELDS PLEASE TYPE N/A IF NOT APPLICABLE

Medical Insurance:

(Please type n/a if not applicable)

Are you the primary cardholder? If no, include primary card holder's Name, DOB and Relationship.

Prescription Drug Plan:

(Please type n/a if not applicable)

Are you the primary cardholder? If no, include primary card holder's DOB and Relationship.

Medicare Fields:

*Is the patient age 65 or older or Medicare Eligible? *Please type n/a if not applicable

Note: MBI is required for all patients age 65 and older, or Medicare eligible. please bring the Red, White, and Blue card.

*If uninsured, you must check the box below to attest that the following information is true and accurate:

1. Have you ever received a dose of COVID-19 vaccine?
If Yes, which vaccine product?
2. Are you feeling sick today?
3. Have you ever had a severe allergic reaction (e.g., anaphylaxis) in the past?

Example: a reaction for which you were treated with epinephrine or EpiPen®, or for which you had to go to the hospital?

Have you had a severe allergic reaction after receiving a COVID-19 vaccine?
Have you had an allergic reaction after receiving another vaccine or injectable medication?
Have you had a allergic reaction related to receiving Polyethylene Glycol or products containing Polyethylene Glycol?
4. Have you received any vaccines in the past 14 days?
5. Do you have a bleeding disorder or are you taking a blood thinner?
6. For women, are you currently pregnant or breastfeeding?
7. Are you immunocompromised or are you on a medicine that affects your immune system?
8. Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g. diabetes), anemia, or other blood disease?

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CONSENT FOR SERVICES: I have beenprovidedwiththeVaccineInformation
Sheet(s) or patient fact sheet corresponding to the vaccine(s) that I am receiving.
I have read the information provided about the vaccine I am to receive. I have had
the chance to ask questions that were answered to my satisfaction. I understand
the benefits and risks of vaccination and I voluntarily assume full
responsibility for any reactions that may result.IunderstandthatIshould
remaining the vaccine administration area for 15 minutes after the vaccination to
be monitored for any potential adverse reactions. I understand if I experience
side effects that should do the following: call the pharmacy, contact the doctor, call 911.
I request that the vaccine be given to me or to the person named above for
whom I am authorized to make this request.

COVID-19 Program for Uninsured Patients is correct. I authorize the release of all records to act on this request. I request that payment of authorized benefits be made on my behalf.

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DISCLOSURE Of Records: I understand that A&D Pharmacy may 

be required to or may voluntarily disclose my health information to the physician responsible for this protocol of specific health information of people vaccinated at A&D Pharmacy (if applicable), my Primary Care Physician (if I have one), my insurance plan, health systems, and hospitals, and/or state or federal registries, for purposes of treatment, payment or other healthcare operations (such as administration or quality assurance). I also understand that A&D Pharmacy will use and disclose my health information as set forth in the A&D Pharmacy Notice of Privacy Practices (a copy is available in-store, online, or by requesting a paper copy from the pharmacy).

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AUTHORIZATION TO REQUEST PAYMENT: I do hereby authorize A&D Pharmacy® to release information and request payment. I certify that the information given by me in applying for payment under Medicare or Medicaid, or the HRSA is accurate.

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