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Covid-19 Vaccine Informed Consent

YOU MUST:

  • Answer all the questions and complete every section of the consent form.
  • Submit one form for each patient.

If any of the following questions are not clear, please ask your health care provider for assistance.

NOTE: Once you have signed up for your first and second dose appointments, please do not sign up for any additional appointments. Vaccine supply is very limited, and we want to ensure as many patients as possible have access to schedule an appointment.

TIME TO COMPLETE:

5-10 minutes.

TIME TO PROCESS:

15-20 minutes.

REQUIRED DOCUMENTS:

Please have your insurance card and Medicare Part B red, white, blue card (if Medicare recipient) ready to upload.

Location

Due to limited vaccine supply, appointments may not be available at all locations. We are updating available time slots daily. If your preferred location does not have openings at this time, please check back again via our online scheduler. We are working to roll out other vaccine appointment scheduling options, but cannot implement them until vaccine allocation increases. Please do not call Hy-Vee, as our pharmacies do not have appointments available that are not reflected online.

NOTE: Vaccines are allocated for residents in each individual state. You may be asked to show an ID to verify residency. Appointments made in states by non-residents may be cancelled.

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