Walkersville Pharmacy Form Page

First Name

Last Name

Street Address

City

State

Zip Code

Birth Month

Birth Day

Birth Year

Age

Mobile Number

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

First Second

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

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 Walkersville 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 with updates and future offers

I attest that I understand all I need to know about the Covid19 emergency use authorization, the risks associated with this vaccine, and absolve Walkersville 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 Walkersville 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 Walkersville 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 Walkersville Pharmacy for my decision to be vaccinated today, I will pay the above mentioned amount.