Vaccine Consent Form

Vaccine Consent Form
*COVID NOTICE*

We have Moderna's mNexspike available for anyone 65+ years of age OR 18-64 years of age with one underlying condition.
Location of Service*

Sona Asheville (805 Fairview Rd)Sona Arden (106 Long Shoals)
I am using this form to:*

Schedule a weekday appointment for a future date and timeSchedule an upcoming Saturday Flu Clinic appointmentI am in the Pharmacy, immediately receive a vaccination
Sona Asheville Appointment*
Sona Asheville Saturday Appointment
Sona Arden Appointment
Sona Arden Saturday Appointment
How would you like to fill in your information? (lookup available for patients with active prescriptions in the past two years)

Fill in manuallyUse my Fairview profileUse my Arden profileUse my Compounding Profile
Date of Birth Lookup MMDDYYYY
Primary Phone Last 4 Digits
Patient Information
Legal First Name*
Legal Last Name*
Date of Birth*

MonthDayYear
Date
Age*
Gender*
*Notice - A prescription from the child's provider is REQUIRED for persons under the age of 18 (except for the Flu vaccine)
Address*
City*
StateCode*
Zip*
Primary Phone*
Email*
example@example.com
Patient's Doctor Information
Physician Name*
Physician Address
City*
State*
Insurance Information

(if you will be Self Paying, please email vax@sonapharmacy.com to discuss cost)
Example Medicare Part B Card
Select Insurance Carrier*
Third Party Name
MemberID*
RxBIN*
RxPCN
GroupID*
Vaccine Selection(s) & Appointment
Select the vaccine(s) you would like to receive (vaccines listed with an * require a prescription)*

Flu65+ FluCOVID mNexspike 18 years or olderPneumonia (Prevnar20®)ShinglesMeningococcal ACWY (Menomune®,Menactra®, or Menveo®)Meningococcal B (Bexsero® or Trumenba®) (currently unavailable)Tetanus (Td)Tetanus with whooping cough (Tdap)Hepatitis AHepatitis BHepatitis A/BHPVRSV (vaccine available is only for 60 years of age and older)MMR* (currently unavailable)Typhoid (intramuscular)*
Vaccine(s) Selected
Please text the pharmacy at {pharmacyText} to confirm vaccine availability if scheduling within 24 hours of your requested appointment time
Please Answer the Below Questions
Is this your 1st or 2nd dose?

1st dose2nd dose
Do you have one of the following underlying conditions that prompted you to request a COVID vaccination?

YesNo
Asthma
Cancer
Cerebrovascular disease
Chronic kidney disease
Bronchiectasi
COPD
Interstitial lung disease
Pulmonary embolism
Pulmonary hypertension
Cirrhosis
Non-alcoholic fatty liver disease
Alcoholic liver disease
Autoimmune hepatitis
Cystic fibrosis
Type 1 or Type 2 Diabetes
Down Syndrome or other disabilities
Epilepsy
Heart conditions (such as heart failure, coronary artery disease, or cardiomyopathy)
Hemophilia
HIV
Mood disorders (such as depression)
Schizophrenia spectrum disorders
Dementia
Parkinson's Disease
Overweight (BMI ≥ 25kg/m²)
Physical inactivity
Pregnancy or recent pregnancy
Primary immunodeficiencies
Sickle cell disease
Former or current smoker
Solid organ or blood stem cell transplantation
Substance use disorders
Use of corticosteroids or other immunosuppressive medications
Tuberculosis
Are you sick today?*

YesNoDon't Know
Do you have allergies to medications, food (e.g., eggs), yeast, a vaccine component, or latex?*

YesNoDon’t know
Please list allergies
Have you ever had a serious reaction (including fainting) after receiving a vaccination?*

YesNoDon’t know
Has any physician or other healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside a medical setting?*

YesNoDon’t know
Do you have a long-term health problem such as heart disease, lung disease, liver disease, asthma, kidney disease, metabolic disease (e.g., diabetes), anemia, or other blood disorder?*

YesNoDon’t know
Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?Have you been diagnosed with rheumatoid arthritis, ankylosing spondylitis, Crohn’s disease?*

YesNoDon’t know
In the past 3 months, have you taken medications that weaken your immune system, such as cortisone, prednisone, other steroids, or anticancer drugs, or have you had radiation treatments?*

YesNoDon’t know
Have you had a seizure or a brain or other nervous system problem or Guillain-Barré?*

YesNoDon’t know
During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?*

YesNoDon’t know
Have you received any vaccinations in the past 4 weeks?*

YesNoDon’t know
Are you pregnant or is there a chance you could become pregnant during the next month?*

YesNoDon’t know
Do you have a cut, injury, puncture, or open wound that prompted you to get a tetanus shot?*

YesNoDon’t know
For RSV: I am 60 years of age or older and certify I meet one of the following criteria: Chronic lung disease (e.g. COPD or asthma), cardiovascular disease (e.g., heart failure, coronary artery disease), chronic or progressive neurologic or neuromuscular conditions, chronic kidney disease (CKD), chronic liver disease (CLD), diabetes, moderate or severe immunocompromised, chronic hematologic disorders, ANY underlying condition that a provider determines might increase the risk of severe RSV disease, reside in a nursing home or long-term care facility, frailty or advanced age*

Yes
RSVAck
A prescription is required for your tetanus vaccination from your provider.
I understand a prescription is required for a tetanus vaccination from my provider.

Yes
TetanusRxUndrStnd
I certify that I am at least 18 years old or that I am the parent or legal guardian of the minor patient (3-17 years of age for certain vaccines) or 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 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 Vaccine Information Statements on the vaccine(s) I have elected to receive. I also acknowledge that I have had a chance ask questions. I, on the behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns herby agree to release, indemnify, and hold harmless Sona Health, 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 Sona Health, Inc., as applicable, to release my medical or other information to, or through, the NC Immunization Registry 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 Sona Health, Inc., as applicable, with respect to the above requested items and services. I further agree to be fully financially responsible for any co-sharing amounts, including copays, co-insurance, and deductibles, for the requested vaccine(s) including any not covered by my insurance benefits. I understand that if my insurance denies my claim for any reason, I will receive a bill for the above requested vaccine(s) from Sona Health, Inc.*

Clear
(Parent or Guardian if patient is a minor)
Walk-In
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wrkflwalert
Location
PharmacyLocation
Pharmacy Text
Appt Date
FVR Appt Date
ARD Appt Date
WalkinApptDate

MonthDayYear
Date
Hour MinutesAM/PM Option
ARDWalkinApptDate

MonthDayYear
Date
Hour MinutesAM/PM Option
Current Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
DOB
Gend
Should be Empty:

Vaccine Consent Form

Patient Information

Patient's Doctor Information

Insurance Information

Vaccine Selection(s) & Appointment

Please Answer the Below Questions