Required fields are marked with *
Other fields are not required and can be completed on the day of the clinic. However, completing all fields will help streamline the registration process.
Consent for Service
I verify that I have been provided with and have read (or had read to me) (1) the Fact Sheet for Recipients and Caregivers for the Emergency Use Authorization (EUA) of the COVID-19 vaccine (“Vaccine”); (2) this COVID-19 Vaccination Consent and Release Form; and (3) any additional information provided to me concerning COVID-19 vaccination. I acknowledge that I have had a chance to ask questions of a healthcare professional about the vaccine. I understand that at this time, some COVID-19 vaccines require 2 doses given 21-28 days apart dependent on the manufacturer. If this is my first dose of the COVID-19 vaccine and a second dose is required, I intend to receive a second dose of the same vaccine in accordance with the timeframe specified in the Fact Sheet to complete the series. I understand the known risks and the potential benefits of receiving the vaccine, and I understand there may be risks to the Vaccine that are not known at this time. I understand that the FDA has authorized use of the vaccine under an Emergency Use Authorization (EUA) and that there is currently not enough scientific evidence available for the FDA to fully approve this or any other COVID-19 vaccine. I nonetheless request and consent to the vaccine being given to me.netheless request and consent to the Vaccine being given to me.
Limitation of Liability
I understand that because this is not an FDA-approved vaccine but is being given under an FDA issued Emergency Use Authorization, KTA Super Stores, its divisions and affiliates and their respective officers, directors, employees, agents and representatives are immune from civil liability under federal and state law for all claims for loss related to any known or unknown side effects and/or injuries, including but not limited to death, that I, or the person for whom I am authorized to make this request, may experience from this vaccine. This immunity means that if I file a lawsuit against KTA Super Stores, the court must dismiss any such lawsuit, and the only exception to this immunity is for claims for willful misconduct.
Authorization to Release Information for Medical Treatment and/or Payment
I understand that I am giving KTA Super Stores permission to release any medical or other information necessary to my physician, Medicare, Medicare HMO, or insurance company, as applicable, to enable KTA Super Stores to process my insurance claims with respect to the vaccination.
Self-Attestation Form for COVID-19 Vaccination:
Moderately to Severely Immunocompromised Patients
CDC recommends that people who are moderately to severely immunocompromised receive an additional dose of an mRNA COVID-19 Vaccine (Pfizer-BioNTech or Moderna) at least 28 days after the completion of the initial mRNA COVID-19 vaccine series.
Patients may self-attest to their condition by completing and signing this form.
Prevaccination Checklist for COVID-19 Vaccines
The following questions will help us determine if there is any reason you should not get the COVID-19 vaccine.
If you answer "yes" to any question, it does not necessarily mean you should not be vaccinated.
It just means additional questions may be asked. If a question is not clear, please ask your healthcare provider to explain it.
Have you ever had an allergic reaction to:
(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.)
A component of a COVID-19 vaccine including either of the following: