COVID Vaccine Consent Form

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Please answer the questions below:
1. Have you ever received a dose of COVID-19 vaccine?
2. Have you ever had an allergic reaction to: (Note that this would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.)
• A component of a COVID-19 vaccine including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures
• A component of a COVID-19 vaccine including Polysorbate, which is found in some vaccines, film coated tablets, and intravenous steroids
• A previous dose of COVID-19 vaccine
• A vaccine or injectable therapy that contains multiple components, one of which is a COVID-19 vaccine component, but it is not known which component elicited the immediate reaction
3. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication? (This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.)
4. 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.
5. Have you received any vaccine 14 days prior to the date you will be scheduling your appointment?
6. Have you ever had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?
7. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?
8. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
9. Do you have a bleeding disorder or are you taking a blood thinner?
10. Are you pregnant or breastfeeding?
11. Do you have dermal fillers?
Please take a picture of the front of your insurance card OR state issue driver's license or ID card. We will not be billing your insurance for the vaccine as the vaccine is free; however, we will bill your insurance for the vaccine administration. You will not have to pay for a COVID vaccine regardless of insurance status.

Medicare patients (including Medicare Advantage Plan): Please submit a copy of your red, white, and blue card - click here for an example.
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Please fill out your insurance information. If you would like to upload an image of your insurance card OR state issued driver's license or ID, please click here. We will not be billing your insurance for the vaccine as the vaccine is free; however, we will bill your insurance for the vaccine administration. You will not have to pay for a COVID vaccine regardless of insurance status. If you do not have insurance, please select "No Insurance" from the dropdown.
Medicare patients (including Medicare Advantage Plan): Please use your Red, White, and Blue Card - click here for an example. Your card will not have a BIN, PCN, or Group.
Please select an available date and time when you would like to visit. This will help us expedite your visit. Please arrive during the time listed in your email confirmation and be prepared to wait at least 15 minutes after you receive your vaccine. If for any reason you are unable to make your appointment, please call us at 828-298-3636 or email vax@sonapharmacy.com to be rescheduled. Our address is:
Sona Pharmacy + Clinic
828-298-3636
805 Fairview Rd, Asheville NC, 28803
Mon-Fri: 8am-8pm, Sat: 9am-6pm, Sun: 11am-6pm
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Please Read and Sign
I certify that I am at least 18 years old or that I am the legal guardian of the patient. I hereby give my consent to the staff of Sona Pharmacy to administer vaccine(s) that I have requested. I understand that it is not possible to predict all possible side effects or complications associated with vaccines. I understand the risks and benefits associated with the above vaccine(s) and have received, read and/or had explained to me the Emergency Use Authorization (EUA) on the vaccine(s) I have elected to receive. I also acknowledge that I have had a chance to ask questions. I, on the behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Blue Ridge Pharmacy, Inc., its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccines listed above. I authorize Blue Ridge Pharmacy, Inc., as applicable, to release my medical or other information to, or through, the COVID Vaccine Management System to my healthcare professionals, Medicare, Medicaid, or other third-party payer as necessary to effectuate care or payment, submit a claim to my insurer for the above requested vaccine(s), and request payment of authorized benefits to be made on my behalf to Blue Ridge Pharmacy, Inc., as applicable, with respect to the above requested items and services.
Sign Above
PHARMACY STAFF ONLY
Please ask the patient: Are you sick today?
Please select an available date for the patient's second dose of the vaccine. For the specified vaccine, the correct timeframe would be:


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Immunizer Signature (Sign Above)
Intern Signature (Sign Above)
Complete And Submit To Pioneer