Please take the time to download and read this updated Comirnaty-Pfizer BioNTech COVID-19 Vaccine EUA Fact Sheet. (Sept. 22, 2021)
Last Name
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First Name (Legal Name)
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Date of Birth (MM-DD-YYYY)
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M-D-Y
Age (in years)
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You must be 12 years of age or older to receive this vaccine.
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I entered the wrong age
I do not meet the age requirements
I entered the wrong age
I do not meet the age requirements
Gender
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Female
Male
Other
Transgender
Unknown
Female
Male
Other
Transgender
Unknown
Local Address Line 1
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State
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AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Zip Code
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Email Address (OU email preferred)
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Phone Number (cell phone number preferred)
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Is this address your permanent address?
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Yes
No, address is temporary
Yes
No, address is temporary
Have you tested positive for COVID-19 within the last 14 days, or are you waiting on results for a COVID-19 test you took because you had an exposure or are having symptoms?
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Yes
No
Are you experiencing symptoms that could be consistent with COVID-19, such as fever, cough, shortness of breath or difficulty breathing, chills, muscle pain, sore throat, recent loss of taste or smell, and/or extreme fatigue?
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Yes
No
Have you had close contact (been within 6 feet, for approximately 15 minutes or more), either at work, at home or in the community, with an individual diagnosed with COVID-19 in the last 14 days or with someone who has been tested for COVID-19 and whose results are pending in the last 14 days? If so, you will need to be cleared by a public health official before receiving your vaccine.
* must provide value
Yes
No
Follow up on "Yes" response to
Have you had any other vaccine in the last 14 days?
Please provide further information.
Above you indicated receiving passive antibodies (e.g. monoclonal antibodies or convalescent plasma) as part of COVID-19 treatment within the past 90 days.
It is recommended that you delay vaccine by 90 days after passive antibody therapy. Unless you keyed in the wrong response above, please end your survey now.
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End survey now
Continue survey and re-key the passive antibodies response above
End survey now
Continue survey and re-key the passive antibodies response above
Follow-up to "Yes' Response to:
I have health conditions, medical history, or concerns about receiving the COVID-19 Vaccine.
Please provide further information.
Follow-up to "Yes' Response to:
Do you have a fever of 100.3 F or greater today?
Please provide further information.
Follow-up to "Yes' Response to:
Do you have severe allergies or reactions to any medications, vaccines, or latex (including anaphylaxis to any substance)?
Please provide further information.
Follow-up to "Yes' Response to:
Have you had a severe allergic reaction after a previous dose of the COVID-19 Vaccine?
Please provide further information.
Follow-up to "Yes' Response to:
Do you have a bleeding disorder or take anticoagulation medication (e.g. Coumadin/warfarin or other blood thinner)?
Please provide further information.
Follow-up to "Yes' Response to:
Do you have any condition (e.g. cancer, HIV/AIDS, rheumatoid arthritis) or take any medications that weakens or compromises your immune system (radiation, steroids). *Will not prevent you from getting the vaccine.
Please provide further information.
Follow-up to "Yes' Response to:
For women, are you or will you be nursing, pregnant, or plan to become pregnant during the course of the multi-phase COVID-19 Vaccine protocol? *Will not prevent you from getting the vaccine.
Please provide further information.
Which dose of the Pfizer BioNTech COVID-19 vaccine will you receive with this appointment?
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Dose 1
Dose 2
Dose 3
Booster Dose (for those who qualify - must be 6 months since the second dose) Dose 1
Dose 2
Dose 3
Booster Dose (for those who qualify - must be 6 months since the second dose)
Currently, CDC is recommending that moderately to severely immunocompromised people aged 12 years of age and older receive an additional dose. This includes people who have:
Active treatment for solid tumor and hematologic malignancies Receipt of solid-organ transplant and taking immunosuppressive therapy Receipt of CAR-T-cell or hematopoietic stem cell transplant (within 2 years of transplantation or taking immunosuppression therapy) Moderate or severe primary immunodeficiency (e.g., DiGeorge syndrome, Wiskott-Aldrich syndrome) Advanced or untreated HIV infection Active treatment with high-dose corticosteroids (i.e., ≥20mg prednisone or equivalent per day), alkylating agents, antimetabolites, transplant-related immunosuppressive drugs, cancer chemotherapeutic agents classified as severely immunosuppressive, tumor-necrosis (TNF) blockers, and other biologic agents that are immunosuppressive or immunomodulatory. The FDA has also authorized through an EUA a third dose (booster) in individuals:
65 years of age and older 18 through 64 years of age at high risk of severe COVID-19 18 through 64 years of age whose frequent institutional or occupational exposure to SARS-CoV-2 puts them at high risk of serious complication of COVID-19 including severe COVID-19 Do you meet one of these criteria or have you been instructed by your medical provider to receive a third dose of the COVID-19 vaccine?
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Yes
No
The third dose of Comirnaty/Pfizer-BioNTech COVID-19 vaccination is recommended 4 weeks after the second dose in immunocompromised individuals. The booster (third) dose of Comirnaty/Pfizer-BioNTech COVID-19 vaccination is authorized 6 months after the second dose.
Do you meet the time interval criteria?
Yes
No
The option " " can only be selected by itself. Selecting this option will clear your previous selections for this checkbox field. Are you sure?
Ethnicity
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Hispanic
Not Hispanic or Latino
Unknown
Prefer not to answer
Hispanic
Not Hispanic or Latino
Unknown
Prefer not to answer
Parent or legal guardian (for all patients under 18 years of age)
First Name Last Name Address Line 1 Address Line 2 City State Zip Relationship Telephone Number:
AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
SERVICES REQUEST AND AUTHORIZATION:
I understand the benefits and risks of the COVID‐19 Vaccination, and I voluntarily assume all risks and take full responsibility for any reactions that may result. I understand I should remain in the vaccine administration area for 15‐30 minutes after the vaccination to be monitored for any potential adverse reactions. I understand if I experience side effects that I should, as appropriate: contact a doctor, call the vaccine provider or call 911 if it is an emergency. I hereby waive any and all claims for damages arising out of or related to this vaccination that I (or anyone claiming on my behalf) may have against OU Health Services and/or the Board of Regents of the University of Oklahoma, including, but not limited to any and all representatives of each, such as (by way of example and not limitation) employees, students, regents, directors, officers, and other healthcare providers of whatever designation. I request that the COVID‐19 Vaccine be given to me or the person named herein, for whom I am authorized to make this request and give consent. I understand and consent to the vaccination being administered by any qualified nurse, student of its Colleges of Pharmacy or Nursing (under the supervision of the respective College’s healthcare professional), or other qualified healthcare provider.
AUTHORIZATION TO REQUEST MEDICARE, MEDICAID, or HRSA REIMBURSEMENT:
In the event I do not have private insurance, I authorize the University or OU Health Services, as applicable, to release information and request reimbursement for administration of this vaccine. I certify that the information given by me for applying for reimbursement by Medicare, Medicaid, or HRSA COVID-19 Program for Uninsured Patients is correct. I authorize the release of all records necessary for reimbursement. I request that payment of authorized benefits be made on my behalf.
DISCLOSURE OF RECORDS:
I understand that a record of my immunization will be maintained and the provider, University or OU Health Services, may be required to or may voluntarily disclose my health information to a physician, health care professional, hospital, clinic , laboratory, pharmacy, medical facility, my insurance plan, and/or state or federal registries, for purposes of treatment, payment, or other health care operations. I also understand that that my health information may be used and disclosed as set forth in the Notice of Privacy Practices maintained by each entity and copies are available as follows:
University: https://apps.ouhsc.edu/hipaa/hpp.asp or contact OU Office of compliance - (405) 271-2511; Anonymous OU Compliance Hotline - (405) 271-2223 / (866) 836-3150.
Signature of patient to receive COVID-19 Vaccine (or parent, guardian, or authorized representative):
By signing on behalf of the patient, you are stating that you are authorized to provide the required representations on behalf of the patient.
Date:
Parent, guardian, or authorized representative:
First Name Last Name Relationship: Phone:
Today's Date (MM-DD-YYYY)
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Today M-D-Y
Please indicate the status of the person who will be receiving the vaccine
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OU Student
OU Employee
Dependent of OU Employee
Dependent of OU Student
Other
OU Retiree
OU Student
OU Employee
Dependent of OU Employee
Dependent of OU Student
Other
OU Retiree
View equation
Health Insurance Card
Please upload or take a photo of your insurance card with your phone/mobile device and then upload it to this box.
The insurance card is being collected to request insurance reimbursement for vaccine administration. If you do not have health insurance, please upload a picture of your ID.
You will not incur any charges for this vaccination.
Please enter your OU ID number listed on the front of your ID card,
(Please enter 0 if you do not have an OU ID.)
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Submit
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