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tIjszpMFaAvKq5R4NHXmCM5uAt4w5VZ4WSfSfYQ44MGICVr6ZoDB9KIDhubrxZL2faYe

Vaccine Screening & Consent

Vaccination clinics are being held in partnership with the USC Pharmacies/USC School of Pharmacy, Los Angeles County Department of Public Health, and Los Angeles Fire Department (LAFD).

Vaccines provided include:

COVID-19 vaccine: Moderna and Pfizer (primary and new bivalent vaccines)
Influenza (flu) vaccine
Monkeypox vaccine (first and second doses)

All vaccines are provided free of charge, with or without health insurance:

All individuals ages 6 months and older are recommended to receive a COVID-19 vaccine (primary series).
All individuals ages 12 years and older are recommended to receive the new COVID-19 vaccine (bivalent booster).
All individuals ages 6 months and older are recommended to receive a flu vaccine every year.
Monkeypox vaccine is available to eligible individuals who may be at high risk.

CLINIC INFORMATION:

For Saturday, October 29:

Clinic Location: Frank Hotchkin Memorial Training Center parking lot, 1700 Stadium Way, Los Angeles, 90012

Clinic Hours: Saturday, October 29, 10 AM - 1 PM

This site is able to vaccinate individuals ages 12 years and older. Parental/guardian consent required for those under 18 years old.

Please complete the questions in the screening and consent form below for to receive the reqeusted vaccines. Thank you!

Today's Date

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M-D-Y

First Name

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Middle Initial

Last Name

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Sex (assigned at birth)

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Male

Female

Other

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Gender Identity

Male

Female

Transgender male

Transgender female

Non-binary/Gender non-conforming

Other

Prefer not to state

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Date of Birth (MM/DD/YYYY)

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M-D-Y

Age (years)

View equation

Street Address

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City

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State

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Zip Code

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Phone Number

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Email Address

The following information is requested to report to the California Immunization Registry (CAIR): Mother's First Name

Race (choose one)

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American Indian / Alaskan

Asian

Native Hawaiian or Other Pacific Islander

Black / African-American

White

Multiracial

Other Race

Unknown Race

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Ethnicity (choose one)

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Hispanic or Latino

Not Hispanic or Latino

Unknown Ethnicity

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What type of health insurance do you have?

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Medi-Cal/Medicaid

Medicare

Private Insurance (ex. Anthem, Blue Cross)

Kaiser Permanente

Other insurance

None

I don't know

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[Optional] Last 4 of Social Security Number. This will help us find your insurance information

[Optional] If available, please update a photo of the FRONT of your insurance card.

Upload file

[Optional] If available, please update a photo of the BACK of your insurance card.

Upload file

Have you ever had an allergic reaction to any of the following (check all that apply to you):

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 caused hives, swelling, or respiratory distress, including wheezing.

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None, no allergies or history of allergic reactions

Any vaccine or an injectable medication

Polyethylene glycol (PEG), polysorbate, citric acid or ethanol, latex, or formaldehyde

Gentamicin, ciprofloxacin, chicken or egg protein

Check all that apply to you:

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None

Feeling sick today

Pregnant or breastfeeding

Immunocompromised or have a weakened immune system

Have a history of Guillain-Barre Syndrome (GBS)

Which vaccine(s) are you requesting to receive?

As of September 29, 2022:

All individuals ages 6 months and older are recommended to receive a COVID-19 vaccine (primary series).
All individuals ages 12 years and older are recommended to receive the new COVID-19 vaccine (bivalent booster).
All individuals ages 6 months and older are recommended to receive a flu vaccine every year.
Monkeypox vaccine is available to eligible individuals who may be at high risk.

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COVID-19 (Primary Doses)

COVID-19 (Bivalent Booster)

Flu

Monkeypox

Have you ever received a flu shot in past years?

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Yes

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What was the date of your most recent flu shot? (Approximate date is okay)

M-D-Y

Have you ever received a dose of the COVID-19 Vaccine?

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Yes

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If Yes: Which COVID-19 vaccine(s) did you receive?

If available, please bring a copy of your vaccination card to your appointment.

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Moderna

Pfizer

Janssen (J&J)

Novavax

Other brand

I don't know

How many doses of the COVID-19 vaccine have you already received?

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What is the date of your most recent COVID-19 Vaccine?

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M-D-Y

This question will help us evaluate whether it is safe to receive the requested vaccines. Check all that apply to you.

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None

Have a history of myocarditis or pericarditis

Have been treated with monoclonal antibodies or convalescent serum to prevent or treat COVID-19

Diagnosed with Multisystem Inflammatory Syndrome (MIS-C or MIS-A) after a COVID-19 infection

Have a bleeding disorder or take a blood thinner

Have a history of heparin-induced thrombocytopenia (HIT)

Have a history of thrombosis with thrombocytopenia syndrome (TTS)

Have a history of COVID-19 disease within the past 3 months

Do you consider yourself to be...

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Gay or lesbian

Bisexual

Straight or heterosexual

Not sure

Something else

Prefer not to state

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Are you currently experiencing symptoms of Monkeypox? (e.g. fever, muscle aches, headache, swollen lymph node)

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Yes

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Have you recently been diagnosed with monkeypox?

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Yes

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Monkeypox vaccine is available to eligible groups defined by LA County found here: http://publichealth.lacounty.gov/media/monkeypox/vaccine.htm

Do you belong to any of the occupational or non-occupational risk groups?

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None

Healthcare Worker/Responder

Laboratory Worker

Non-occupational High Risk of Exposure

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Do you have a history of keloid scar formation?

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Yes

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Have you ever received a dose of the JYNNEOS Vaccine?

* must provide value

Yes

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What was the date of your most recent monkeypox vaccine?

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M-D-Y

Have you had a COVID-19 mRNA vaccine (Pfizer or Moderna) within the last 4 weeks, or are you planning on receiving a COVID-19 mRNA vaccine within the next 4 weeks?

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Yes

Unsure

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CLICK "ADD SIGNATURE" THEN USE YOUR MOUSE OR FINGER TO SIGN

I understand and acknowledge that vaccinations are being provided by licensed personnel through USC School of Pharmacy.

I hereby release, discharge and hold harmless University of Southern California and USC Pharmacies, and its officers, directors, employees, members, subsidiaries, agents, successors, and assigns from any and all liability that may arise, directly or indirectly, now or in the future, by reason of any injury, damage, loss, or expense incurred in connection with my receiving a vaccination today.

I certify that the information provided above has been completed to the best of my knowledge.

I have reviewed (or will have the opportunity to review) the Emergency Use Authorization (EUA) Fact Sheet for Recipients and Caregivers or Vaccine Information Sheet (VIS), if applicable, and had (or will have) a chance to ask questions that were answered to my satisfaction. I fully understand the possible risks and side effects of vaccinations.

I consent to the vaccination being provided for myself or the person named above for whom I am authorized to make this request.

Unless I decline, I understand that this information will be reported to the California Immunization Registry or CAIR.

I authorize the USC Pharmacies to release information and request payment to my health plan. I certify that the information given by me in applying for payment is correct. I request that the payment of authorized benefits be made on my behalf. To sign, please click "Add signature" then use your mouse or finger to create a signature.

SIGNATURE: To sign, please click "Add signature" then use your mouse or finger to create a signature.

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Add signature

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