Immunization or Injection Consent Form

Name*

First NameLast Name

Date of Birth*

Date

Sex*

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Address*

Street Address

Street Address Line 2

CityState

Zip Code

What organization are you affiliated with? *

Are you sick today or taking antibiotics/antiviral medications?*

YesNo

Do you have allergies to medications, food, any vaccine or latex?*

Yes. Please explain below.No

Please explain:

Please explain: blanks blank

Have you ever had a serious reaction after receiving a vaccine?*

Yes. Please explain below.No

Please explain:

Have you received any vaccines in the past month?*

Yes. Please explain belowNo

Please explain:

Please explain: blanks blank

Do you have any long term health problems such as heart, lung, kidney, liver disease, diabetes, anemia, etc.*

YesNo

Are you pregnant?*

YesNo

Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?*

YesNo

In the past 3 months have you taken medications that affect your immune system (steroids, chemo drugs, drugs for RA, Crohn's, or other autoimmune disease)?

Yes. Please explain belowNo

Please explain:

Please explain: blanks blank

In the past year have you received a blood or blood product transfusion or been given a drug called immunoglobulin?*

YesNo

Have you ever been diagnosed with Guillain-Barre?*

YesNo

I have been given a copy and have read, or had explained to me, the information contained in the Vaccine Information Statement about the disease and vaccine. I understand the benefits and risks of the vaccine and request that the vaccine be given to me or the person for whom I am authorized to make this request. I agree that this information may be shared with schools, daycare centers, healthcare providers and others when medically necessary. I have been given a copy of the Brent's Pharmacy & Diabetes Care Notice of Privacy Practices and have had a chance to ask questions about how my public health information will be used. I understand that it is my responsibility to know what my insurance plan covers and agree to pay the portion not covered by my insurance. I understand that if Brent's Pharmacy & Diabetes Care does not have a contract with my insurance company, or my insurance company denies payment, I am responsible for all charges incurred.

I request that the specified vaccine/injection be given to me or the person named above, for whom I am the parent or legal guardian.

Vaccine/Injection

Signature*

Date*

Date

Insurance Card:

Upload a photo of your insurance card here