Vaccine Consent Form
for all available vaccines
Vaccine Recipient Name
*
First Name
Middle Name
Last Name
Vaccine Recipient Physical Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Date of Birth
*
/
Month
/
Day
Year
Gender at birth
*
Please Select
Male
Female
Vaccine Recipient Phone Number
*
Format: (000) 000-0000.
Primary Care Provider (Doctor) Name
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Vaccine Screen Questions
*
Rows
Yes
No
1. Are you feeling sick today?
2. Do you have allergies to medications, food (eggs), a vaccine component, or latex?
3. Have you ever had a serious reaction after receiving a vaccination?
4. Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, diabetes, anemia, or other blood disorder?
5. Do you have cancer, leukemia, AIDS, or any other immune system problem?
6. Do you take cortisone, prednisone, other steroids, or anticancer drugs, or have you had radiation treatment?
7. Have you had a seizure or a brain/other nervous system problem?
8. During the past year, have you received a transfusion of blood/blood products or been given a medicine called immune (gamma) globulin or an antiviral drug?
9. Are you pregnant or is there a chance you could become pregnant in the next month?
10. Have you received any vaccinations in the past 4 weeks?
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Which vaccine are you getting today?
*
COVID (not available) (age 65+ or under 65 with high risk for severe COVID-19)
Influenza (Flu) Regular Dose
Influenza (Flu) High-Dose (65 years and older)
Pneumonia
RSV
Shingrix (Shingles)
Tetanus with Pertussis (Whooping Cough) (TdaP)
Other
Select an appointment time (note time zone if out of state):
*
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Vaccine Consent
I have read the vaccination information sheet, regarding the vaccine(s) marked above. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s). I consent to, or give consent for, the administration of the vaccine(s) marked above and the notification of my primary care physician. I fully release and discharge Medicine Man Bonners Ferry, its affiliates, their officers, directors, and employees from any liability for illness, injury, loss, or damage which may result there from.
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):
*
Please print the name of the person who signed above
*
Medicare Part B Customers: I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment above.
Date Signed
*
/
Month
/
Day
Year
Date
Submit (Required)
Should be Empty: