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
Please choose your vaccine *

Influenza vaccine Pneumovax-23 Shingrix
Choose a payment method. Payment must be received before vaccine administration. *

Self Pay Commercial Insurance *Please call with insurance information as needed.
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 this vaccine before? *

Yes NO
Is your immune system suppressed in any way? *

Yes NO
Explain "Yes" response above.
Do you have a cochlear implant? *

Yes NO
Have you had any problems or serious reactions to vaccines 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.
Do you have a history of Guillain-Barre Syndrome? *

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 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
After your form is submitted, a member of our pharmacy team will contact you to schedule your immunization.
Should be Empty:

Consent to Vaccination

VIS Sheet