Shingrix Vaccine Consent Form

Shingrix® Vaccine Consent Form

Zoster Vaccine Recombinant, Adjuvanted
First Name
Middle Initial
Last Name
DOB:
Gender

MaleFemale
Address

Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Home Phone:
Cell Phone:
SS#:
Email address:
example@example.com
Race:

WhiteBlack or African AmericanAsianAmerican Indian or Alaska NativeHispanic, Latin, or SpanishNative Hawaiian or Pacific Islander
Primary Physician:
Past Medical History
Have you ever had an allergic reaction to the Shingrix® vaccine?

YesNo
Do you have an immunosuppressive condition or disease?

YesNo
Do you have a moderate or severe infection today (with greater than 101.3 degrees or without fever)?

YesNo
Do you take immunosuppressive therapies including irradiation, antimetabolites, alkylating agents, anti-TNF, cytotoxic drugs, or are you HIV infected, a transplant recipient, have an autoimmune disorder, have had a splenectomy, or taking steroids (>20mg/day) for more than 2 weeks or a recent immunization?

YesNo
Consent to Immunize
I have reviewed a copy of the Vaccination Information Statement (VIS) and have had the opportunity to ask questions about the risks and benefits of this vaccination.

YesNo
I understand common side effects may include aches or muscle pain, fatigue, headache, shivering, fever, gastrointestinal symptoms, malaise, and injection site redness, swelling, or pain and that the benefits include disease prevention.

YesNo
This vaccination record may be reported to the Texas Department of Health Immunization Tracking Service and primary healthcare providers.

YesNo
I consent for the vaccination to be administered to me and for the immunizer to initiate the emergency medical plan if necessary due to a reaction to the vaccination.

YesNo
I am aware of the potential risks and side effects of the vaccine as described in the literature as well as the risk of the disease it prevents. I hereby waive any liability towards Valmed Pharmacy Solutions and/or its administering employee of potential adverse effects associated with administration of the vaccine. I authorize the release of any medical or other information necessary to process the claim and I hereby assign all insurance, Medicare, Medicaid, and other third-party payors’ benefits for services rendered. I have been offered the HIPAA Privacy Policy. I understand that third party payors may not cover the vaccination and I agree to pay for services rendered.
Signature of the person receiving the vaccine or Guardian, if recipient is unable to sign.

Clear
Date

MonthDayYear
Date
Relationship (If unable to sign)
Medical Health Insurance Card

Browse Files
Health insurance plans may cover the vaccination Cancelof
RX Benefit Insurance Card

Browse Files
RX Benefit may cover the vaccination Cancelof
Should be Empty:

Shingrix® Vaccine Consent Form

Past Medical History

Consent to Immunize