Baltimore Highlands Pharmacy Form Page

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Please Complete the Information Below

Company

First Name *

Last Name *

Email *

Street Address *

City *

State *

Zip Code *

Month *

Day *

Year *

Mobile Number *

Click here to review the Pfizer-BIONTECH COVID-19 Fact Sheet:

https://www.fda.gov/media/144414/download

Click here to review the Moderna COVID-19 Fact Sheet:

https://www.fda.gov/media/144638/download

Click here to review the Janssen COVID-19 Fact Sheet:

https://www.fda.gov/media/146305/download

Is this your first or second COVID-19 vaccination?* *

First Second

Are you a healthcare employee or professional? *

Yes No

Are you a resident of a Long Term Care Facility? *

Yes No

Are you an Essential Worker (Education / Food & Agriculture / Utilities / Police / Fire / Corrections / Transportation)? *

Yes No

Do you have any of the following chronic health conditions? *

Cancer

Chronic Kidney Disease

COPD (Chronic Obstructive pulmonary disease)

Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies

lmmunocompromised state (weakened immune system) from solid organ transplant

Obesity (body mass index [BMI] of 30 kg/m2 or higher but< 40 kg/m2)

Severe Obesity (BMT > = 40 kg/m2)

Pregnancy

Sickle Cell disease

Smoking

Type 2 diabetes mellitus

None of the above

Have you previously received a COVID-19 vaccine? *

Yes No I Don't Know

Have you had a severe allergic reaction (e.g., anaphylaxis) to a COVID-19 vaccine, 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) or Polysorbate? *

Yes No I Don't Know

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.) *

Yes No

Do you have a bleeding disorder or are you taking a blood thinner? *

Yes No I Don't Know

Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies? *

Yes No I Don't Know

Do you have a fever? *

Yes No I Don't Know

Are you feeling sick? *

Yes No I Don't Know

Are you pregnant? *

Yes No I Don't Know

Could you become pregnant in the next several weeks? *

Yes No I Don't Know

Are you breastfeeding (nursing)? *

Yes No I Don't Know

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

Yes No I Don't Know

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 *

Yes No I Don't Know

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

Yes No I Don't Know

Have you had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19? *

Yes No I Don't Know

Insurance Information:

Medicare ID Number

From Red, White, and Blue card if disabled or over 65 years of age

Health Insurance Plan Name

ID Number

RxBin

RxPCN

RxGroup

Pharmacy Most Often Used

Would you like to have your prescriptions transferred to Baltimore Highlands Pharmacy and filled there in the future?

Yes No

Important Information:

If you receive Pfizer-BI0NTECH's vaccine, you should receive a second vaccination three weeks (21 days) later.

If you receive Moderna's vaccine, you should receive a second vaccination four weeks (28 days) later.

contact me

Contact me with updates and future offers

i attest

I attest that I understand all I need to know about the Covid19 emergency use authorization, the risks associated with this vaccine, and absolve Baltimore Highlands Pharmacy of any harm, injury, or death that could occur due to my being vaccinated today, and attest that I meet all the requirements for receiving a Covid19 vaccine in the state of Maryland, and fall within the current, active vaccination phase for Maryland residents. I understand that if I answer yes to this question, I absolve Baltimore Highlands Pharmacy of all legal, moral, and ethical responsibilities if I have mislead them on the grounds of my eligibility to receive this vaccine, and will bear my percentage of any punitive charges levied against Baltimore Highlands Pharmacy that may have resulted from any failure, intentional or not, to act in accordance with Maryland guidelines regarding Covid19 vaccinations. These charges are not to exceed $50 for each patient, unless the state, CDC, vaccine manufacturers, my healthcare insurance company, or pharmacy benefits manager (PBM) chooses to pursue legal action or recoupment directly against me for my actions, for which I will accept the full burden of payment and responsibility. If any of these entities pursue recoupment or legal action against Baltimore Highlands Pharmacy for my decision to be vaccinated today, I will pay the above mentioned amount.