Ray's Pharmacy Immunization Consent Form

Patient Name*

First NameMiddle InitialLast NameSuffix

Birth Date:*

Date

Age on Date of Vaccination*

Sex*

MaleFemale

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number*

Email*

example@example.com

Primary Care Provider and Office Phone*

Will we be billing insurance for your vaccinations?*

Is your insurance billed through Medicaid, Commercial, Medicare?*

Do you have a Medicare Advantage Plan?*

Medicare Number*

Number on Red, White, and Blue card

RX BIN

RX PCN

Member ID

RX Group

Provider 1/DSHS number*

Enter a 0 in the RX BIN, RX PCN, RX ID, and RX Group if you do not have a Molina, Community Health Plan of WA, or United Health through Apple Care.

If you are unsure if you have a Medicare advantage plan, please provide us with your Medicare Number and a brief description of what plan you have for prescriptions. We may reach out to you before your scheduled appointment for clarification.

Vaccine to receive? Select all that apply*

Will you be needing any accommodations for your scheduled appointment?

Example: I will need the vaccines administered in my car.

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.

1. Are you sick today?*

YesNoDon't Know

If "Yes" or "Don't know" to #1 please describe.

2. Do you have any allergies to Medications, Food, Latex or a vaccine component?*

YesNoDon't Know

If "Yes" or "Don't know" to #2 please describe.

3. Have you ever had a serious reaction after receiving a vaccination?*

YesNoDon't Know

If "Yes" or "Don't know" to #3 please describe.

4. Do you have any of the following: a long-term health problem with heart, lung, kidney, or metabolic disease (e.g., diabetes), asthma, a blood disorder, no spleen, a cochlear implant or a spinal fluid leak? Are you on long-term aspirin therapy*

YesNoDon't Know

If "Yes" or "Don't know" to #4 please describe.

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

YesNoDon't Know

If "Yes" or "Don't know" to #5 please describe.

6. Do you have a parent or sibling with an immune system problem?*

YesNoDon't Know

If "Yes" or "Don't know" to #6 please describe.

7. In the past 6 months, have you taken medications that affect your immune system such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Chron's disease, or psoriasis; or have you had radiation treatments?*

YesNoDon't Know

If "Yes" or "Don't know" to #7 please describe.

8. Have you had a seizure, brain, or other nervous system problem?*

YesNoDon't Know

If "Yes" or "Don't know" to #8 please describe.

9. In the past year, have you received immune (gamma) globulin, blood/blood products, and an antiviral drug?*

YesNoDon't Know

If "Yes" or "Don't know" to #9 please describe.

10. Are you pregnant?*

YesNoDon't Know

If "Yes" or "Don't know" to #10 please describe.

11. Have you received any vaccinations in the past 4 weeks?*

YesNoDon't Know

If "Yes" or "Don't know" to #11 please describe.

12. Have you ever felt dizzy or faint before, during, or after a shot?*

YesNoDon't Know

If "Yes" or "Don't know" to #12 please describe.

13. Are you anxious about getting a shot today?*

YesNoDon't Know

If "Yes" or "Don't know" to #13 please describe.

All our vaccinations are logged on the Washington Immunization System and can be accessed by most health care providers should they need to see your records

A vaccine, like any medicine, is capable of causing serious problems, such as severe allergic reactions. The risk of any vaccine causing serious harm, or death, is extremely small. Local symptoms may include: slight tenderness, redness, itching or swelling at the site of injection. Systemic symptoms may include: fever, malaise and muscle pain. Other systemic symptoms may occur infrequently. These reactions usually begin 6 to 12 hours after immunization and can persist for a few days. Immediate presumable allergic reactions such as hives, angioedema, allergic asthma or systemic anaphylaxis occur rarely after immunization. These reactions may result from hypersensitive reactions in people with severe egg allergy, and such people should not be given certain vaccines that contain eggs. People with documented immunoglobulin E (IgE)-mediated hypersensitivities to eggs or any other vaccine components, including thimerosal, may also be at increased risk of reactions from immunizations. In the case of a severe reaction such as a high fever, behavior changes or flu-like symptoms that occur after vaccination, see a doctor right away. Signs of an allergic reaction can include difficulty breathing, hoarseness or wheezing, hives, paleness, weakness, a fast heartbeat, or dizziness within a few minutes to a few hours after the shot.

I have read the adverse reactions associated with the administration of vaccines. A copy of the vaccine manufacturer’s drug information sheet is available on request. Furthermore, I have also had an opportunity to ask questions about these immunizations. 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(s) or the receipt of the immunization(s) by the person named below for whom I am the legal guardian (‘Ward’). My medical record may be shared with my physician or other healthcare provider and the medical record of my Ward may be shared with his/her physician or other healthcare provider. I am requesting that the immunization(s) be given to me or my Ward. I, for myself and on behalf of my Ward, and each of our respective heirs, executors, personal representatives and assigns, hereby release Ray’s Pharmacy, and its affiliates, subsidiaries, divisions, directors, contractors, agents and employees (collectively “Released Parties”), from any and all claims arising out of, in connection with or in any way related to my receipt and the receipt by my Ward of this or these immunization(s). Neither Ray’s Pharmacy nor any of the Released Parties shall, at any time or to any extent whatsoever, be liable, responsible or any way accountable for any loss, injury, death or damage suffered or sustained by any person at any time in connection with or as a result of this vaccine program or the administration of the vaccines described above. Ray’s Pharmacy will use and disclose your personal and health information or the personal and health information of your Ward, to treat you or your Ward, to receive payment of the care we provide, and for other health care operations. Healthcare operations generally include those activities we perform to improve the quality of care. We have prepared a detailed NOTICE OF PRIVACY PRACTICES to help you better understand our policies in regard to you and your Ward’s personal health information. I acknowledge that I have received a copy of the Notice of Privacy Practices.

Form completed by:*

Enter your name or the person filling out this form

Date*

Date