For Your Records

[CVS Pharmacy <http://www.notification.cvshealth.com/~pharmacy>]

Please save or print this email for your personal records. Private and 
confidential. Intended for patient or caregiver only. If you have received 
this document in error, please notify CVS Pharmacy immediately.
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Please keep this for your records

Hi ROBERT,

Thanks for choosing CVS Pharmacy ® . This email contains a record
of your recent vaccination.

If you’re 18 or older, you can view this and other CVS Pharmacy
or MinuteClinic health records in your health dashboard
https://www.care.cvs.com/login?CID=EM_H4L_202103_VRO . To access
vaccination records for a minor, you first have to add them to your
account by requesting to manage their prescriptions through your pharmacy
dashboard https://www.cvs.com/pharmacy/ .

View Record https://www.care.cvs.com/login?CID=EM_H4L_202103_VRO

Vaccine administration record

Patient information
-----------------------------------------------------------------------

Vaccine administration information
-----------------------------------------------------------------------

Store information
-----------------------------------------------------------------------

Need a more detailed record?

The summary above and online may not include complete information or serve as 
proof of vaccination in some states. If your state needs more details, try the 
following options:
   1  If you signed a vaccination consent form on paper, we gave you a paper 
   copy of your official Vaccine Administration Record
   2  If you gave us your primary care provider's information, contact them 
   for a copy
   3  See if your state has an immunization registry
   4  Call CVS Pharmacy
[IMAGE] ,https://www.cvs.com/bizcontent/ux_images/arrow.png,

How was your vaccine experience?

Take 1 minute to rate your vaccination experience with CVS Pharmacy 

https://survey.medallia.com/?cvs-imz-vaccinerecord&storeID=09812&visittype=Store&oppID=06a9af7df3ed47feb0a472f061503742&doseNumber=3&imzType=COVID
and share your thoughts.

Consent for services

CONSENT FOR SERVICES: I have received and read (or had read to me) the Vaccine 
Information Statement(s), Vaccine Information Fact Sheet(s) and/or Patient 
Fact Sheet(s) regarding the vaccine(s). I understand the benefits and risks of 
vaccination. I voluntarily assume full responsibility for any reactions or 
consequences that may result. I understand that I should remain in the vaccine 
administration area for 15 minutes, or longer if directed, after the 
vaccination to be monitored for potential adverse reactions. In the event of 
side effects, I understand I should call the pharmacy, my doctor, or 911. I 
certify that the information provided regarding eligibility for the vaccine is 
accurate and request that the vaccine be given to me or to the person 
previously named for whom I am authorized to make this request. If I am 
signing on behalf of another individual (including a minor), I attest that I 
have the authority to do so. Please note the following must have the consent 
of a parent or guardian: Patients in Alabama/Nebraska under 19 years old; 
patients in South Carolina under 16 years old; and patients under 18 years old 
in all other states. If I am receiving a COVID-19 third dose, I attest that I 
am eligible for that dose because I am immunocompromised. State of Georgia 
only: I verify a pharmacist asked for my health history and whether I have had 
a physical exam within the past year. Health care providers did not identify 
conditions(s) that would mean I should not receive vaccine(s).

AUTHORIZATION TO REQUEST PAYMENT: I authorize CVS Pharmacy ® ("CVS ® ") to 
release medical information to Medicare, Medicaid or any other third party 
payer as needed and to request payment of authorized benefits to be made on my 
behalf to CVS. I certify that the information provided about my Medicare, 
Medicaid or other coverage is correct.

ACCEPTANCE OF FINANCIAL RESPONSIBILITY: Notwithstanding anything previously 
set forth, I agree that I am responsible for and will promptly pay on demand 
any and all obligations to CVS Pharmacy including all self-pay balances as 
well as those charges for services not covered or disallowed by my insurance 
carrier (For non-COVID-19 vaccines).

DISCLOSURE OF RECORDS: I understand that CVS ® may be required to or may 
voluntarily disclose my health information with respect to this vaccine to my 
healthcare providers, my insurance plan, health systems and hospitals, and/or 
state or federal registries. I understand that CVS will use and disclose my 
health information as set forth in the CVS Notice of Privacy Practices (copy 
is available in-store, online or by requesting a paper copy from the pharmacy)
. State of Ca only: I agree to have the Ca Immunization 
Registry (CAIR) share my immunization data with health care providers, 
agencies or schools. State of FL only: Students 18-23 may opt out of the 
immunization registry by notifying pharmacy prior to administration Vaccine 
Clinics: If I am receiving a vaccine through a vaccine clinic, I understand 
that my name, vaccine appointment date and time will be provided to the clinic 
coordinator.

Signature electronically captured

Consent date: 07/16/2022

Screening questions

Are you sick today? (For example: a cold, fever or acute illness)

N

Do you have allergies or reactions to any foods, medications, vaccines or 
latex? (For example: eggs, gelatin, neomycin, thimerosal, etc.) or have you 
ever had a severe allergic reaction (e.g., anaphylaxis) to something? For 
example, a reaction for which you were treated with epinephrine or EpiPen®, 
or for which you had to go to the hospital? If yes, what are you allergic to?

N

Do you have a bleeding disorder or take blood thinners such as 
Warfarin/Coumadin?

N

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

N

Do you currently or have you in the past 14 days, had a fever, chills, cough, 
shortness of breath, difficulty breathing, fatigue, muscle or body aches, 
headache, new loss of taste or smell, sore throat, nausea, vomiting, or 
diarrhea?

N

Have you tested positive for COVID-19 within the last 14 days?

N

Have you ever had a severe allergic reaction after receiving a COVID-19 
vaccine?

N

Have you ever had a severe allergic reaction after receiving another vaccine 
or injectable medication?

N

Have you ever had a severe allergic reaction after receiving Polyethylene 
Glycol?

N

Have you ever had a severe allergic reaction related to receiving Polysorbate 
or products containing Polysorbate?

N

Have you received monoclonal antibodies or convalescent plasma as part of a 
COVID-19 treatment in the past 90 days?

N

Do you have a history of an immune-mediated syndrome characterized by 
thrombosis (abnormal blood clots) and thrombocytopenia (low platelets), such 
as heparin- induced thrombocytopenia (HIT)?

N

Do you have a history of myocarditis (inflammation of the heart muscle) or 
pericarditis (inflammation of the lining around the heart) either related to 
or unrelated to receipt of an mRNA COVID-19 vaccine?

N

Are you moderately/severely immunocompromised from a medical 
condition/immunosuppressive therapy, including/not limited to: active 
treatment for solid tumor/hematologic malignancy, solid organ/stem-cell 
transplant, primary immunodeficiency syndrome, advanced/untreated HIV 
infection, or active treatment with high dose corticosteroids/other 
immunosuppressive/ immunomodulatory biologic agents?

N

Do you have a history of Guillain-Barré syndrome (GBS)?

N

Do you have a history of multisystem inflammatory syndrome (MIS-C or MIS-A)?

N

Do you have a history of thrombosis with thrombocytopenia syndrome (TTS) 
following the Janssen COVID-19 vaccine or any other adenovirus-vectored 
COVID-19 vaccines (e.g., AstraZeneca¿s COVID-19 vaccine)?

N

Pharmacist notes:

Patient's Temperature: 97.5f

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

CVS  Pharmacy logo

© 2021 CVS Pharmacy Inc.
One CVS Drive,
Woonsocket, RI 02895

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