Immunization Consent Form
Please have your pharmacy insurance card ready when completing
Payment
Vaccines may be billed to your pharmacy benefits. Please contact your plan directly if you have questions regarding insurance coverage of vaccines.
Choose a payment method
*
My insurance is already on file
Pay out of Pocket
Commercial Insurance
Medicare Part D/ Medicare Advantage
Insurance Card Information
Please input each of the following for your insurance card
Bin number
PCN
Rx Group
Identification Number
Patient Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Gender
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Female
Male
Patient Phone Number
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Format: (000) 000-0000.
Vaccine(s) to receive?
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Influenza
FluMist Intranasal
Pneumonia (Prevnar20)
RSV (Arexvy)
Shingles (Shingrix)
Tetanus/Diptheria/Pertussis (TDaP)
Other
Primary Care Provider (PCP) Name
First Name
Last Name
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.
Are you sick today?
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Yes
No
Do you have any allergies to medications, food, eggs, yeast, latex, or a vaccine component?
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Yes
No
Have you ever had a serious reaction after receiving a vaccination?
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Yes
No
Has any physician or healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a medical setting?
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Yes
No
Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (diabetes), anemia or other blood disorders?
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Yes
No
Do you have cancer, leukemia, HIV/AIDS, or any other immunological disorder? Have you been diagnosed with rheumatoid arthritis, ankylosing spondylitis, Crohns disease, herpes, or cold sores?
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Yes
No
In the past 3 months, have you taken medications that weaken your immune system such as cortisone, prednisone, other steroids, or anticancer drugs, or have you had radiation treatments?
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Yes
No
Have you had a seizure, brain/other nervous system problem or Guillain Barre?
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Yes
No
During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug (including acyclovir, famciclovir, valacyclovir)?
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Yes
No
Have you received any vaccinations or TB skin test in the past 4 weeks?
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Yes
No
Do you have a history of fainting, particularly with vaccines?
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Yes
No
For women: Are you pregnant or is there a chance you could come become pregnant during the next month?
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Yes
No
N/A
For Tdap and adult Td: Do you have a cut, injury, puncture or open would that prompted you to get a tetanus shot?
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Yes
No
N/A
For Shingles (Zoster) vaccine: Have you had a past reaction to gelatin or triple antibiotic ointment?
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Yes
No
N/A
Consent to Vaccination and Assignment of Benefits
I have read, or have had read to me, the written information regarding the vaccine(s) being administered. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s) being administered and have received a copy of a current Vaccine Information Sheet. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Elmwood Pharmacy and Home Medical Equipment, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s). I certify that I am at least 18 years old and hereby give my consent to the pharmacists of this pharmacy to administer the vaccine(s). If under 18 years old signature by parent or guardian is required. I agree to wait near the vaccination location for approximately 15 minutes for observation by the pharmacist. I assign the right and responsibility to Elmwood Pharmacy to bill on my behalf, and accept payment for Medicaid/Third party insurance products and services provided for me. I understand that I am responsible to pay any deductible amount applied to the claims and I permit Elmwood pharmacy to release and collect my health information, and other information as required from my health care providers and insurance. I understand this assignment will be maintained and made available to my insurance company or its representatives.
Form completed by
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First Name
Last Name
Signature of Person Receiving the Immunization (or Parent/Guardian of person < 18 years old)
Pharmacy Use Only
Do no complete the below questions
Signature of Pharmacist
Signature/Title of Immunization Administrator
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