VACCINE ADMINISTRATION RECORD (VAR) AND INFORMED CONSENT FOR VACCINATIONS

VACCINE ADMINISTRATION RECORD (VAR) AND INFORMED CONSENT FOR VACCINATIONS
SECTION A:
Name

First NameMiddle InitialLast Name
Age:
Gender:
Race:
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Mother's Maiden Name
Address

Address

Street Address Line 2

CityState

Postal / Zip Code
Phone:
Primary Care Physician:
Physician phone number
Medicare #:
I want to receive the following vaccination(s):
Which arm would you like to receive the vaccine?
Have you had a physical exam in the past year?
SECTION B:
ALL VACCINES
Do you feel sick today?
Are you experiencing any symptoms of COVID-19 including: Fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea?
If so, which symptoms?
Do you have any health conditions such as heart disease, diabetes, or asthma?
If so, please list:
Do you have allergies to latex, medications, food, or vaccines? (Ex: eggs, gelatin, thiomersal, bovine protein)
Have you ever had a reaction after receiving an immunization including fainting or feeling dizzy?
Have you ever had a seizure disorder for which you are on seizure medication(s), a brain disorder, Guillian-Barre Syndrome, or other nervous system problems?
For women: Are you pregnant or considering getting pregnant in the next month?
SECTION C: I authorize Carmichael’s to administer the vaccine and to bill my insurance for this service. I understand if I have a copay

or my insurance does not cover this service, I am responsible for the cost of the service.
Patient/Parent/Guardian Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
SECTION D: (HEALTHCARE PROVIDER ONLY)
Immunizer Name:
Signature:
If applicable, intern name (print):
VACCINE
SITE OF ADMINISTRATION
LOT NUMBER
EXPIRATION DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

VACCINE ADMINISTRATION RECORD (VAR) AND INFORMED CONSENT FOR VACCINATIONS

SECTION A:

SECTION B:

ALL VACCINES