Below this text is SIMILAR to what your flow will look like for your COVID vaccines. The red blocks will explain the thought process or what is occuring at each section.

Be sure to go through the whole process. At the end of the COVID Vaccine Consent form you can schedule a "fake" appointment. Once you do that you will see all of the emails that your patient will receive and that you would receive as the pharmacy.

Based on your answers it will be like one of those "choose your own adventure" books. That might date me a little. ;) However, just like those books, you can go back and forth to see how each section changes based on your answers.

Looking forward to helping you out!

YOUR Pharmacy LOGO HERE

The red boxes are instructions and explanations for you. We use your pharmacy specific colors on the forms and there will be no "red boxes".

COVID Phase & Initial Qualification Questionnaire

REMEMBER: We can make simple changes to these forms and it NOT be considered "custom work". But this is similar to the flow we will create for you.

Welcome to our COVID vaccine enrollment process!!

These first few questions are health qualifications that can definitely disqualify you from receiving the vaccine. You may have to answer these again in your consent form.

We ask you these questions immediately because we don't want you to make a trip to get your vaccine and then get turned away.

Please enter your name, email address, and the phone you are most likely to answer below IF you would like to be placed on a standby list if you don't currently qualify. IF we have vaccine remaining at the end of a vaccination day we may call even if you don't currently qualify to make sure no vaccine goes to waste.

You do NOT have to have a standby list. The verbiage here can be easily changed.

First Name *

Last Name *

Best Number to Reach You *

If you want to see how the form will TRULY work for you, you will need to put in your actual email address. You will receive automated emails at the end showing you what you would receive at the pharmacy and what the patient would receive upon completion.

Email Address *

Please Confirm Your Email Address *

We place some of the automatic disqualification questions right up front so someone doesn't end up taking an appointment time only to show up and not be able to receive the vaccine. You can choose to do this or NOT to do this.

Have 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

Have you ever had an allergic reaction to Polysorbate? *

Yes

Have you ever had an allergic reaction to the COVID-19 vaccine? *

Yes

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

Yes

Have you tested positive for COVID in the past 90 days? *

Yes

Have you been exposed to someone in the past 14 days that was currently positive for COVID-19? *

Yes

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

Yes