• Immunization Consent Form

    Please have your pharmacy insurance card ready when completing
  • Please select how you would like to receive the immunization*

  • 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*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Insurance Card Information

    Please input each of the following for your insurance card

  • Please enter insurance information here:

  • Format: (000) 000-0000.

  • Medicare Information

    Please input each of the following with your Medicare information

  • Please text a picture of your red, white, and blue Medicare card (and pictures of your your Medicare Advantage Card if applicable) through our secure text system along with the patient's name and date of birth to 706-543-7386!

  • Do you have a Medicare Advantage Plan?
  • Format: (000) 000-0000.
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender*

  • Medication Allergies: *

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • 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? (currently have a fever or an acute illness)*
  • Have you had a physical exam with the past year?*
  • Have you ever had a serious reaction after receiving a vaccination?*
  • Do you have allergies to medications, eggs, or other food, a vaccine component, or latex?*
  • Have you ever felt dizzy or faint before, during, or after a shot?*
  • Are you anxious about getting a shot today?*
  • Are you pregnant?*
  • Have you received any vaccinations in the past 4 weeks?*
  • Vaccine(s) to receive?*
  • Do you have a long-term health problem such as heart, lung, kidney, or metabolic disease (e.g. diabetes), asthma, a blood disorder, a cochlear implant, or spinal fluid leak? Are you on long term aspirin therapy?*
  • Have you had a seizure, brain disorder, or other nerve problem?*
  • Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?*
  • Do you have a parent or sibling with an immune system problem?*
  • In the past 6 months, have you taken any medications that affect your immune system, such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn's disease, or psoriasis, or have you had radiation treatments?*
  • Have you ever been diagnosed with a heart condition (myocarditis or pericarditis) or have you had Multisystem Inflammatory Syndrome (MIS-A or MIS-C) after an infection with the virus that causes COVID-19?*
  • In the past year have you received immune (gamma) globulin, blood or blood products, or an antiviral drug?*

  • Consent to Vaccination

    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 Duvall Family Drugs, 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.

  • Pharmacy Use Only

    Do no complete the below questions
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: