Vaccine Consent Form

Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Phone Number *

Area Code Phone Number
Email
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Primary Care Provider (PCP) Name *

First Name Last Name
PCP Phone Number *

Area Code Phone Number
The HD flu vaccine is not available. Please choose FluBlok below if you are 65 and older.
Vaccine(s) to receive? *

Influenza FluZone Quad (Suitable for 6 months and older) Influenza FluBlok Quad (18 years and older *Please choose this ONLY if you have an egg allergy or if you are over 65 and unable to receive the HD vaccine)
Where do you want your immunization to take place? *

Private patient room inside Altitude Drug Curbside at Altitude Drug Big Piney Thursday, October 29th INSIDE store. 215 Budd Ave Big Piney Thursday, October 29th CURBSIDE. 215 Budd Ave
If you choose curbside in Pinedale, please come to the drive-thru window to let us know you are here. We will direct you to a parking spot and meet you outside.

If you choose curbside in Big Piney, please call 231-0860 when you arrive.
Choose a payment method. *

Influenza vaccines are currently FREE for Sublette County residents while supplies last! If you are not a Sublette County resident please choose an option below. Self Pay Commercial Insurance
For Patients: The following questions will help us determine which vaccines you may be given today. If you answer "Yes" to any question it does not necessarily mean you should not be vaccinated today. It just means additional questions maybe asked. If a question is not clear, please ask us to explain it.
Form completed by? *

First Name Last Name
Are you Currently Sick? *

Yes NO
Do you currently have a fever? *

Yes NO
Do you have any reason to believe you are infected with COVID-19 or have been in contact with someone with COVID-19 within the last 14 days? *

Yes NO
Are you currently waiting on the results of a COVID-19 test? *

Yes NO
Have you had the flu vaccine before? *

Yes NO
Did you have any problems with the flu vaccine before? *

Yes NO If yes, explain.
Explain "Yes" response above.
Do you have allergies to latex, eggs, or any other vaccine component? *

Yes NO
Explain "Yes" response above.
Have you ever fainted after receiving a vaccine? *

Yes NO
Explain "Yes" response above.
Have you ever had serious reaction after receiving a vaccine? *

Yes NO
Explain "Yes" response above.
Do you have a history of Guillain-Barre Syndrome? *

Yes NO
Have you taken influenza antiviral medication in the last 48 hours? *

Yes NO
Are you pregnant? *

Yes NO
Please show up on time.

Please wear a short sleeve shirt.

Masks are required. If you do not have a mask, one will be provided. Thank you!
Consent to Vaccination

I hereby claim that the above information is true and correct to the best of my knowledge. I consent that pharmacists affiliated with Altitude Drug LLC may administer this vaccine. I have been informed of the risks and benefits of the vaccine via the CDC-issued Vaccine Information Statement (VIS). I give permission to Altitude Drug to seek compensation through my insurance, if applicable, knowing that my insurance may not fully cover the associated costs of the vaccine and administration. If this occurs, I understand that I am fully responsible for all costs associated with the administration of the vaccine. I also give consent to have this vaccine information shared as necessary with appropriate parties, including my healthcare provider and the immunization registry, Wyoming Statewide Immunization Information System.
VIS Sheet

I have read the adverse reactions associated with the administration of influenza vaccines. A copy of the vaccine manufacturer's drug information sheet has been made available to me at AltitudeDrug.com. I am aware that it is recommended I wait for 15 minutes after receiving my vaccine. Furthermore, I have also had an opportunity to ask questions about the immunization. I believe the benefits outweigh the risks and I voluntarily assume full responsibility for any reactions that may result from either my receipt of the immunization or the receipt of the immunization by the person named below for whom I am the legal guardian ("Ward"). Please type your name below to indicate consent to treatment.
Signature *

Clear
Appointment
Should be Empty:

Consent to Vaccination

VIS Sheet