COVID-19 Vaccine Forms

rxAssist Pharmacy

Please correct the errors described below.

See if you're eligible in your state

You state specific criteria may include:

  • Age restrictions
  • Field of employment (healthcare workers, essential workers, etc.)
  • Health conditions

If you don't meet your state's eligibility criteria for a COVID-19 vaccination, you are not eligible to receive a vaccination at this time.

How it works

  1. Register at rxAssist pharmacy website.
  2. Complete a short screening
  3. If you're eligible, you'll be able to schedule appointments for both your Dose 1 and Dose 2 vaccination at the same time.
  4. If you feel ill on the day of your vaccination, please reschedule your appointment when you feel health and well.

For your appointment, please arrive 15 minutes early and bring the following:

  • Your appointment confirmation email
  • Your state ID, valid driver's license or other government-issued ID
  • Your medical, pharmacy benefit or medicare insurance card

INSURANCE INFORMATION

Prescription Insurance

Medical Insurance


Medicare

If uninsured answer the question below to attest,

Please Note:In order to have your vaccine administration fee paid for by the United States Health Resources and Services Administration's COVID-19 Program for Uninsured Patients, please provide either (A) a valid Social Security numer, (B) State Identification number and state of issuance, OR (C) A driver's license and the state of issuance.

COVID-19 Screening Questions

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Immunization Screening Questions

CONSENT FOR SERVICES: I have been provided with the Vaccine Information Sheets(s) or patient fact sheet corresponding to the vaccine(s) that I am receiving. I have read the information provided about the vaccine that I am to receive. I have had the chance to ask questions that were answered to my satisfaction. I understant the benefits and risk of vaccination and I voluntarily assume full responsibility for any reactions that may result. I understand that I should remain in the vaccine administration area for 15 minutes after the vaccination to be monitored for any potential adverse reactions. I understan if I experience side effects that I should do the following: call pharmacy, contact doctor, call 911. I request that the vaccine be given to me or the persone named above for whom I am authorized to make this request.


DISCLOSURE OF RECORDS: I understand that rxAssist pharmacy may be required to or may voluntarily disclose my health information to the protocol physician, my primary care physician, my insurance plan, health systems and hospitals, and/or federal registries, for the purpose of treatment, payments, or other healthcare operations. The disclosure will used as set forth by rxAssist Notice of Privacy Practice.

MODERNA COVID-19 FACTS SHEET

PFIZER COVID-19 FACTS SHEET

JOHNSON & JOHNSON COVID-19 FACTS SHEET

RXASSIST PRIVACY POLICY

Disclaimer: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Please Note:If signing on behalf of the patient, you are stating that you are authorized to provide the required consents on behalf of the patient.

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Next of Kin (18 or younger)

for CA, MA, MT, NJ, NM, NY, TX (For CA, this indicator means the registry will not share university, Schools, or other agencies)

Private and Confidential. Intended for patient or caregiver only. If you have received this document in error, please notify rxAssist Pharmacy immediately.

TO BE PLACED ON THE WAITING LIST

Your information will be encrypted.

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