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IN2HfJIMNWamzBcfaAMDCSSI5rVi9XV8Jtu4yLIVLSQHKyY2cXnm5XjkW4TtkJbBXqGnNr2RfYWZHSH

Covid-19 Vaccine Screening & Consent/ Evaluación y consentimiento de la Vacuna de Covid-19

Please complete the survey below prior to arriving for your COVID-19 Vaccination appointment with USC Pharmacies/

Complete la encuesta a continuación antes de llegar a su cita de la Vacuna de de COVID-19 con USC Pharmacies

Today's Date / Fecha de hoy

* must provide value

M-D-Y

First Name / Primer nombre

* must provide value

Last Name / Apellido

* must provide value

Middle Initial / Inicial del segundo nombre

Gender / Género

* must provide value

Male / Hombre

Female / Mujer

Other / Otro

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

[Optativo] Los últimos 4 números de su número de seguro social. Esto nos ayudará a encontrar su información de seguro médico

Date of Birth (MM/DD/YYYY) /
Fecha de nacimiento (DD/MM/AAAA)

* must provide value

M-D-Y

Age (years) / Edad (años)

* must provide value

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Address / Dirección

* must provide value

City / Ciudad

* must provide value

State / Estado

* must provide value

Zip Code / Código postal

* must provide value

Phone Number / Número de teléfono Number

* must provide value

Email/ Correo electrónico

* must provide value

I am attending the vaccine event on:

* must provide value

Friday May 7th

Saturday May 8th

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

Se pide la siguiente información para reportarlo al Registro de inmunizaciones de California (CAIR): Primer nombre de su madre

Race (choose one) / Raza (elija una)

* must provide value

American Indian / Alaskan | Native Nativo de América / Alaska

Asian | Asiático

Native Hawaiian or Other Pacific Islander | Nativo de Hawái u otra isla del pacífico Negro

Black / African-American | Afroamericano

White | Blanco

Other Race | Otra raza

Unknown Race | Raza desconocida

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Ethnicity (choose one) / Etnicidad (elija una)

* must provide value

Hispanic or Latino | Hispano o latino

Not Hispanic or Latino | No hispano ni latino

Unknown Ethnicity | Etnicidad desconocida

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What type of health insurance do you have? /

¿Qué tipo de seguro médico tiene?

* must provide value

Medi-Cal/Medicaid

Medicare

Private Insurance (ex. Anthem, Blue Cross) / Seguro privado

Kaiser Permanente

L.A. Care

Blue Shield Promise

Other insurance / Otro seguro

None / Ninguno

I don't know / Yo no sé

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[Optional] Please upload a photo or copy of the FRONT of your health insurance card. /

[Optativo] Suba una foto o copia de la parte DELANTERA de su tarjeta de seguro médico

Upload file

[Optional] Please upload a photo or copy of the BACK of your health insurance card. /

[Optativo] Suba una foto o copia de la parte POSTERIOR de su tarjeta de seguro médico

Upload file

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

¿Ha recibido alguna vez una dosis de la vacuna contra el COVID-19?

* must provide value

Yes / Sí

I Don't Know / No sé

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If Yes, Which Covid-19 vaccine did you receive? /

Si la respuesta es "sí", ¿cuál vacuna le pusieron?

* must provide value

Moderna

Pfizer

Janssen

I don't know / No sé

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What is the most recent date that you received the COVID-19 Vaccine? /

¿Cuál es la fecha más reciente en la que recibió la vacuna de COVID-19?

M-D-Y

YES

I DON'T KNOW

Have you ever had an allergic reaction to polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures? / ¿Ha tenido alguna vez una reacción alérgica a lo siguiente? - Polietilenglicol (PEG), que se encuentra en algunos medicamentos como los laxantes y preparaciones para los procedimientos de colonoscopia?

* must provide value

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Have you ever had an allergic reaction to polysorbate, which is found in some vaccines, film coated tablets, and intravenous steroids. / ¿Ha tenido alguna vez una reacción alérgica a lo siguiente? - Polisorbato, que se encuentra en algunas vacunas, pastillas o comprimidos recubiertos y esteroides intravenosos.

* must provide value

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Have you ever had an allergic reaction to Citric acid or Ethanol? / ¿Alguna vez ha tenido una reacción alérgica al ácido cítrico o al etanol?

* must provide value

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Have you ever had an allergic reaction to a previous dose of COVID-19 vaccine? / ¿Ha tenido alguna vez una reacción alérgica a lo siguiente? - Una dosis previa de la vacuna contra el COVID-19.

* must provide value

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Have you ever had an allergic reaction to a vaccine or injectable therapy that contains multiple components, one of which is a COVID-19 vaccine component, but it is not known which component elicited the immediate reaction? / ¿Ha tenido alguna vez una reacción alérgica a lo siguiente? - Una vacuna o terapia inyectable que contenga múltiples componentes, uno de los cuales sea un componente de la vacuna contra el COVID-19, pero no se sabe cuál provocó la reacción inmediata.

* must provide value

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Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication? / ¿Ha tenido alguna vez una reacción alérgica a otra vacuna (que no sea la vacuna contra el COVID-19) o a un medicamento inyectable?

* must provide value

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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. / ¿Ha tenido alguna vez una reacción alérgica grave (p. ej., anafilaxis) a otra cosa que no sea un componente de la vacuna contra el COVID-19, o a alguna vacuna o medicamento inyectable? Esto incluye alergias a alimentos, mascotas, venenos, medioambiente o medicamentos que se toman por la boca.

* must provide value

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Have you received any vaccine in the last 14 days? / ¿Ha recibido alguna vacuna en los últimos 14 días?

* must provide value

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Have you ever had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19? / ¿Ha tenido alguna vez un resultado positivo en la prueba del COVID-19 o un médico le ha dicho que usted tuvo COVID-19?

* must provide value

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Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? / ¿Ha recibido terapia pasiva con anticuerpos (anticuerpos monoclonales o suero de convaleciente) como tratamiento para el COVID-19?

* must provide value

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Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies? / ¿Tiene el sistema inmunitario debilitado debido a algo como infección por el VIH o cáncer, o toma medicamentos o terapias inmunodepresores?

* must provide value

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Do you have a bleeding disorder or are you taking a blood thinner? / ¿Tiene un trastorno hemorrágico o toma un anticoagulante (blood thinner)?

* must provide value

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Are you pregnant or breastfeeding? / ¿Está embarazada o amamantando?

* must provide value

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Do you have dermal fillers? / ¿Tiene materiales de relleno dérmico (dermal fillers)?

* must provide value

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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 Pharmacy.

I hereby release, discharge and hold harmless University of Southern California and USC Pharmacy, 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.

This Notice and Release of Liability shall be binding on my heirs, executors, administrators, successors, and assigns.

I further certify that:

I am at least eighteen (18) years of age and fully competent; or
I am under eighteen (18) years of age, and my parent/ guardian is also signing individually and on my behalf and we both agree to be bound by the terms of this Notice and Release of Liability.I certify that the information provided above has been completed to the best of my knowledge.

I understand that completion of this form does not guarantee vaccination.

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.

I acknowledge that the pharmacy is legally obligated to report my COVID-19 vaccination to the local department of public health. 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.

I consent to receiving my health information related to COVID-19 vaccination by unencrypted email and/or text message. I understand that email and text message is not a completely secure means of communication because these messages can be addressed to the wrong person or accessed improperly while in storage or during transmission. If I opt out, I can request to receive a paper copy of my record instead.

EspañoL

Haga clic en “Add Signature" (Agregar firma) y use su ratón o dedo para firmar.

Entiendo y reconozco que personal licenciado de USC Pharmacy está administrando las vacunas.

Por medio de la presente libero, renuncio y eximo a, University of Southern California y USC Pharmacies, y sus oficiales, directores, empleados, miembros, subsidiarios, agentes, sucesores y beneficiarios de toda responsabilidad que surja directa o indirectamente, ahora o en el futuro, por razón de cualquier herida, daño, pérdida o gasto sufrido en conexión con el recibir una vacuna hoy.

Este Aviso y exención de responsabilidad será obligatorio para mis herederos, albaceas, administradores, sucesores y beneficiarios.

Además certifico que:

Tengo por lo menos dieciocho (18) años y soy plenamente competente;
Tengo menos de dieciocho (18) años y mi padre/tutor también firma individualmente y por mi parte y los dos accedemos sujetarnos a los términos de este Aviso y exención de responsabilidad.

Doy fe que la información que se proveyó anteriormente se completó de acuerdo a mi conocimiento.

Entiendo que completar este formulario no garantiza la vacunación.

He revisado (o tendré la oportunidad de revisar) la Hoja informativa para receptores y proveedores de cuidado de la Autorización de uso urgente (EUA) o Declaración de Información Sobre la Vacuna, si aplica, y tuve (o tendré) la oportunidad de hacer preguntas que se contestaron a mi entera satisfacción. Entiendo completamente los posibles riesgos y efectos secundarios de las vacunas.

Consiento que me provean la vacuna a mí o a la persona nombrada anteriormente por la que tengo autorización de hacer esta petición.

A menos que lo decline, entiendo que se reportará esta información al Registro de inmunizaciones de California o CAIR.

Autorizo a USC Pharmacies a divulgar datos y pedir pago de mi plan de seguro médico. Certifico que la información que di para solicitar pago es correcto. Pido que se paguen las prestaciones autorizadas en mi nombre. Para firmar, haga clic en "Add signature" (Agregar firma) y entonces use su ratón o dedo para crear la firma.

Doy mi consentimiento para recibir mi información médica relacionada con la vacuna COVID-19 por correo electrónico y / o mensaje de texto sin cifrar. Entiendo que el correo electrónico y los mensajes de texto no son un medio de comunicación completamente seguro porque estos mensajes pueden dirigirse a la persona equivocada o accederse a ellos de manera incorrecta mientras están almacenados o durante la transmisión. Si opto por no participar, puedo solicitar recibir una copia impresa de mi registro.

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If signed by another other than the patient, please mark the box below to describe your relationship to the patient. /

Si lo firma alguien que no es el paciente, por favor marque la caja a la derecha para describir su relación con la paciente.

Parent / Padre/Madre

Guardian / Tutor

Other Authorized Individual / Otro individuo autorizado

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Click "Add Signature" then use your mouse or finger to sign.

I certify that the information above has been provided to me by the Patient (or other qualified person authorized to act on their behalf). The Patient (or other qualified person acting on their behalf) orally consented after I read the registration, screening, and consent material above. The Patient was given an opportunity to ask questions and has given consent to submit this information on their behalf.

* must provide value

Add signature

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.