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  • 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.

  • 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.
  • Clear
  • After your form is submitted, a member of our pharmacy team will contact you to schedule your immunization. 

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