Consent Form

Flu Testing click here

Vaccine Consent Form click here

Testing cost $50.

Payment is due at check-in at the pharmacy.

Note: schedule appt 30 in advance

*COVID NOTICE*

We have Moderna's mNexspike available for anyone 65+ years of age OR 12-64 years of age with one underlying condition.

Location of Service

Fairview Rd

Long Shoals

I am using this form to:

Select Carehub Service Type

Select Carehub Test

Sona Asheville Appointment (805 Fairview Rd)

Sona Asheville Point of Care Testing Appointment (805 Fairview Rd)

Sona Asheville Saturday Appointment

Sona Arden Appointment (106 Long Shoals)

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)

Date of Birth Lookup MMDDYYYY

Primary Phone Last 4 Digits

Current Profile Information

Name: {legalFirst} {legalLast}	Date Of Birth: {dateOf}
Address: {address}	Physician: {physicianName}
{city114} {statecode} {zip115}	Insurance: {thirdParty}
Primary phone: {primaryPhone9}	MemberID: {memberid}
Email: {email}	Bin: {rxbin}

Legal First Name

Legal Last Name

Date of Birth

Date

Age

Gender

Weight and Height

Patient BMI

*Notice - A prescription from the child's provider is REQUIRED for persons under the age of 18 (except for the Flu and COVID vaccine)

Address

City

StateCode

Zip

Primary Phone

Format: (000) 000-0000.

Email

example@example.com

Physician Name

Physician Address

City

State

Example Medicare Part B Card

Select Insurance Carrier

Insurance

MemberID

RxBIN

RxPCN

GroupID

Select the vaccine(s) you would like to receive

Vaccine(s) Selected

Please text the pharmacy at {pharmacyText} to confirm vaccine availability if scheduling within 24 hours of your requested appointment time

Healthcare provider recommended to receive a COVID vaccination
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

Is this your 1st or 2nd dose?

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

Type a question

Are you sick today?

Do you have allergies to medications, food (e.g., eggs), yeast, a vaccine component, or latex?

Please list allergies

Have you ever had a serious reaction (including fainting) after receiving a vaccination?

Has any physician or other healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside a medical setting?

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?

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?

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?

Have you had a seizure or a brain or other nervous system problem or Guillain-Barré?

During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?

Have you received any vaccinations in the past 4 weeks?

Are you pregnant or is there a chance you could become pregnant during the next month?

Do you have a cut, injury, puncture, or open wound that prompted you to get a tetanus shot?

For RSV: I am 50 years of age or older and certify I meet one of the following criteria: chronic lung or respiratory disease (e.g. COPD, emphysema, asthma, interstitial lung disease, or cystic fibrosis), chronic cardiovascular disease (e.g., heart failure, coronary artery disease, or congential heart disease excluding isolated hypertension), neurologic or neuromuscular conditions causing impaired airway clearance or respiratory muscle weakness (e.g. poststroke dysphagia, amyotrophic lateral sclerosis, or musclar dystrophy excluding history of stroke without impaired airway clearance), end-stage renal disease or dependence on hemodialysis or other renal replacement therapy, chronic liver disease (e.g. cirrhosis), diabetes complicated by chronic kidney disease, neuropathy, retinopathy, or other end-organ damage or requiring treatment with insulin or sodium-glucose cotransporter-2 (SGLT2) inhibitor, moderate or severe immunocompromised, chronic hematologic disorders (e.g. sickle cell disease or thalassemia), severe obesity (BMI >=40kg/m² or higher), residence in a nursing home, OR other chronic medical conditions or risk factors that a healthcare provider determines would increase the risk of severe disease due to viral respiratory infection (e.g. frality, situations in which healthcare providers have concern for presence of undiagnosed chronic medical conditions, or residence in a remote or rural community)*

RSVAck

A prescription is required for your tetanus vaccination from your provider.

I understand a prescription is required from my provider.

RxUndrStnd

Medical Provider

Current Medications

(prescription, over the counter, herbals, topical medications, pain or allergy medication, and any supplements/vitamins)

Treatments tried for current condition

if none, please indicate N/A

Do you have any of these symptoms which are sometimes caused by the flu?

SymptomsNow

Date

When did these symptoms start?

Date

dayscalc

When were you exposed to a person with the flu?

Date

Select Yes for any that apply

Rows	Yes
Are you Pregnant of Breastfeeding?
Are you currently receiving treatment for cancer, such as chemotherapy or radiation? This includes treatment for blood cancers like leukemia, lymphoma or multiple myeloma
Have you ever had an organ or stem cell transplant and are you currently taking medications to prevent your body from rejecting it?
Has a doctor ever told you that you have a weakened immune system due to a condition you were born with such as DiGeorge syndrome, Wiskott-Aldrich syndrome or Bruton Disease?
Have you been taking medications that weaken the immune system like steroids (such as prednisone) for more than 2 weeks?
Do you have sickle cell anemia?
Have you ever been diagnosed with HIV or AIDS?
Do you use oxygen at home or need extra oxygen to help you breathe?
Are you 19 years of age on younger and taking aspirin every day or on a regular basis for a health condition?
Has your doctor ever told you that you have kidney problems, or kidney disease, but that you don't need dialysis?
Has you doctor ever told you that you have breathing problems such as asthma, COPD or cystic fibrosis?
Has your doctor ever told you that you have heart problems such as heart disease, heart failure, blocked arteries or problems with blood flow to your heart?
Do you have diabetes?
Are you of American Indian or Alaska Native descent?
Have you received the influenza vaccine FluMist Nasal Spray in the last 2 weeks?
Have you ever had an allergic reaction to medicine used to treat the flu? For example, did you have trouble breathing, a rash, or swelling after taking flu medicine like oseltamivir (Tamiflu)?
Have you ever had any side effects after taking flu medicine in the past? (like nausea, vomiting, diarrhea, abdominal pain, dizziness, difficulty breathing, wheezing)
Are you on dialysis or has your doctor ever told you that you have kidney failure?
Have you taken medicine for the flu in the last 4 weeks (like Tamiflu or another antiviral)?

Comments (please use this space to write any extra information or notes you want the pharmacist to know)

dialysis

4weekflumed

inputs

Eligible Service

Thank you for completing our questionnaire! Based on the information provided, we can provide testing as well as education about results and home self-care. However, we would not be able to prescribe a prescription for flu treatment.

Thank you for completing our questionnaire! Based on the information provided, we would not be able to prescribe a prescription for flu prevention.

By signing this form, you are saying that you understand and agree to the following: I have flu-like symptoms (like a fever, cough, sore throat, body aches, or feeling very tired), or I have been around someone with the flu and want to be checked to see if I should take medicine to help prevent or treat it. A licensed pharmacist will ask me about my symptoms and health history. If I qualify, the pharmacist will do a quick flu test using a nose swab. The pharmacist will use this information to decide what to do next. If I need a flu test, the pharmacist will review my test results and how I am feeling and may: Give me medicine to treat the flu, or Tell me to go to a doctor’s office, urgent care, or emergency room if I need more help. I understand that flu medicine works best if taken early. It can help me feel better faster and make my symptoms less severe. If I start to feel worse, don’t get better, or have side effects from the medicine, I will contact my regular doctor. I know it’s important to have a regular doctor. If I don’t have one, I can ask the pharmacist to help me find one. Consent: I give permission for the pharmacist to test me for the flu, check my symptoms, and give me treatment if needed. I understand the pharmacist is allowed to do this under state-approved rules. I understand this visit will be written down and shared with my doctor.

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.

(Parent or Guardian if patient is a minor)

Parent or Guardian Name

First NameLast Name

Testing cost $50. Payment is due at check-in at the pharmacy.

POCT Symptons

When did symptons start?

Date

Did you get your flu shot this year?

Are you a smoker?

Carehub Current Medications

Any other recent medical concerns?

ED Memo

Compared to others your age, how is your health?

How would you describe your gender?

Are you pregnant?

Do you get medical treatment for any of the following health conditions? *Choose all that apply

Do you get treatment for any of the following mental health conditions? *Choose all that apply

How many different prescriptions and overthecounter medications do you take each day?

In the past year, how may times have you stayed overnight as a patient in the hospital?

In the past 6 months, how may times have you been a patient in an Emergency Room (ER)?

Choose all services you have had in the past months

Do you need help with any of these activities? *Choose all that apply

Do you have the help you need with activities like bathing, eating or getting dressed?

How often do you feel isolated from others?

Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things?

Over the last two weeks, how often have you been feeling down, depressed or hopeless?

In the past 12 months, did you worry that your food would run out before you got the money to buy more?

In the past 12 months, did he food you bought just not last and you didn't have the money to get more?

In the past 12 months, have you had a steady place to live?

In the past 12 months, have you had trouble getting utilities when needed? Examples are heat, water and electricity.

In the past 12 months, have you had trouble getting things you need because you didn't have a ride?

Do you feel physically or emotionally unsafe where you live right now? Call local police if you need immediate help. *National Domestic Violence Hotline: 1-800-799-7233 or text the word START to 88788

In the past 12 months, have you ben hit, slapped, kicked or physically hurt by anyone? *National Domestic Violence Hotline: 1-800-799-7233 or text the word START to 88788

In the past 12 months, has anyone emotionally abused you? Examples are being bullied or intimidated. *National Domestic Violence Hotline: 1-800-799-7233 or text the word START to 88788

Do you use tobacco products or vape?

Has alcohol or drug use made it hard for you to work, keep relationships or meet goals?

What is your race or ethnicity? *Choose all that apply

Person Answering

Person Answering Relationship

Other

How would you describe your child's gender?

Is your child pregnant?

Does your child currently need or take medication prescribed by a doctor (other than vitamins)?

Is this because of any medical, behavioral or other health conditions?