COVID Vaccine Screening Form(新冠疫苗 接種登記表)
Medx Pharmacy COVID Vaccine Screening Form (美福藥局 新冠疫苗 接種登記表)
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Health Screening Questions 疫苗接種問答

Please be reminded that completing the questions below prior to your visit can considerably speed up the process. Do your best to answer and we'll confirm later. 請您在接種前點擊並選擇符合您狀況的選項,如果您有任何疑問,歡迎在現場詢問藥師。
Leave it blank if you don't have one. 如果您沒有家庭醫生,請留空白。
如果您沒有上述狀況,請輸入"N/A"。If the question does not apply, you still need to respond. Write "N/A" instead of leaving the space blank.
如果您沒有上述狀況,請輸入"N/A"。If the question does not apply, you still need to respond. Write "N/A" instead of leaving the space blank.

Insurance Information 醫療保險信息

Please fill in your insurance information below. You can ignore this section if you don't have insurance or it is your second appointment with us. 請填寫您的醫療保險信息,如果您沒有保險或您已經在接種第一劑時填寫過,請留空白:
(6-digit number. If you cannot find a Rx BIN on your health insurance card, please give your health insurance a call. )
(PCNs may be alphanumeric or numeric. Not all health insurance plans use PCNs, so it is okay to leave this blank if you don't see it on your health insurance card.)
(Your member ID could be anywhere from 5-12 digits long and should be listed on your health insurance card. It can also be listed under numerous headers, such as "Member ID", "ID #" or "Membership #".)
(RX group numbers can be alphanumeric or numeric. If your Rx Group is not available on your card, you can check by calling your health insurance provider. Otherwise, you may leave this section blank.)
I AGREE TO SHARE MY DATA WITH THE STATE-RUN IMMUNIZATION REGISTRY AS REQUIRED BY MY STATE. I HAVE READ THE INFORMATION ABOUT COVID-19 AND THE JANSSEN COVID-19 VACCINE (JOHNSON&JOHNSON), PFIZER COVID-19 VACCINE OR MODERNA COVID-19 VACCINE. I HAVE HAD A CHANCE TO ASK QUESTIONS THAT WERE ANSWERED TO MY SATISFACTION. I BELIEVE I UNDERSTAND THE BENEFITS AND RISKS OF THE VACCINE CITED AND ASK THAT THE VACCINE BE GIVEN TO ME. I UNDERSTAND THAT IT IS RECOMMENDED THAT I STAY ON LOCATION 15 MINUTES FOLLOWING THE INJECTION.
I UNDERSTAND A DRUG FACT SHEET FOR THE JANSSEN COVID-19 VACCINE IS AVAILABLE AT https://www.janssenlabels.com/emergency-use-authorization/Janssen+COVID-19+Vaccine-HCP-fact-sheet.pdf.
I UNDERSTAND A DRUG FACT SHEET FOR THE PFIZER COVID-19 VACCINE IS AVAILABLE AT https://www.fda.gov/media/144414/download.
I UNDERSTAND A DRUG FACT SHEET FOR THE MODERNA COVID-19 VACCINE IS AVAILABLE AT https://www.fda.gov/media/144638/download.

我同意根據本州要求將我的信息錄入免疫登記處. 我已經閱讀過新冠病毒和Janssen疫苗、Pfizer疫苗或莫德纳疫苗的相關信息. 我有機會提出關於疫苗有關的問題並且我的疑問有被很好地解答. 我理解疫苗利弊和風險並且主動要求施打疫苗. 我明白接種完疫苗以後應在原地等待15分鐘.
我了解强生疫苗的藥品成份表可以在以下網址參閱. https://www.janssenlabels.com/emergency-use-authorization/Janssen+COVID-19+Vaccine-HCP-fact-sheet.pdf.
我了解辉瑞疫苗的藥品成份表可以在以下網址參閱. https://www.fda.gov/media/144414/download.
我了解莫德纳疫苗的藥品成份表可以在以下網址參閱. https://www.fda.gov/media/144638/download.

Internal session

To be filled by Medx Pharmacy 工作人員專用
to be filled internally
to be filled internally
to be filled internally
to be filled internally
to be filled internally